Preventive Service Visits Billed with Other Services

The code edit changes described in the guidelines below will not override HMSA’s existing medical policies.

The edits described below apply to claims processed under the new claims processing system. Nevertheless, HMSA suggests that practitioners adopt the guidelines when filing claims to HMSA for all private business claims.

Modifiers

When billing preventive services visits with other services it is important to bill accurately. In some cases, a modifier code must be appended to the office visit code to ensure that both services are paid when appropriate. Modifiers 25 is generally used for this purpose. Practitioners are urged to familiarize themselves with the criteria listed in CPT and the following policy.

Modifier Code 25

Modifier codes should only be used when the service meets the criteria described in CPT and in HMSA's policies. HMSA will perform postpayment reviews of modifier usage as needed to verify modifiers were used as described. If postpayment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment. See Benefit Overpayment.

Specific edits

The following codes are frequently billed by providers without modifiers when paired with preventive service visits. When this occurs, if the appropriate modifier is not appended to the preventive service visit code, the preventive service visit may not be paid.

Note: The list above is not all inclusive, but represents codes that are most commonly billed with a preventive service visit and to which these guidelines apply.

Revision History