Well check and sick visit combination policy update

Anthem allows applicable provider types to bill for a sick visit for the same recipient (at the same time of service and for the same provider) as a well check and be reimbursed for both visits.

Per the Division of Health Care Financing and Policy’s Web Announcement 2972, when performing both services on the same day, reimbursement for the sick visit may be reimbursed at 50% of contracted rates. Anthem is pleased to share that we will continue to reimburse applicable provider types at 100% of contracted rates for both the sick visit and well check visit when billed in conjunction and with the appropriate diagnosis codes and modifiers for each respective visit.

This policy update under the Early and Periodic Screening, Diagnostic, and Treatment program, Medicaid Services Manual Chapter 1500, impacts the following CPT^® procedure codes:

• Well checks: 99381–99385 and 99391–99395
• Sick visits: 99202–99205 and 99211–99215

The impacted provider types are:

Provider type	Provider type description
12	Hospital, outpatient
20	Physician, M.D., osteopath, D.O.
24	Advanced practice registered nurse
60	School health services
77	Physician's assistant

Billing instructions:

• When billing a well check and a sick visit for the same recipient, on the same day, and at the same time by the same provider, the sick visit must have the U6 and 25 modifiers.
• When billing a well check and a sick visit, and an immunization is administered, both well check and sick visit must have the 25 modifier. The sick visit must also have the U6 modifier.

Important Anthem provider responsibilities:

• Verify member eligibility and prior authorization requirements at each visit.
• Submit a clean claim within timely filing limits:
  • Medicaid: 180 days from the date of service
• If you believe a claim has been improperly adjudicated, submit a reconsideration, dispute, or appeal within timely filing limits:
  • Medicaid: 90 days from the date of original Explanation of Payment or remittance advice

If you do not follow these guidelines, claims may be denied. See the provider manual for more information.