CPT 99213, in plain terms, covers Office or outpatient visit for an established patient with low medical decision making or at least 20 minutes of total time. CPT 99213 is referenced in 50 tracked payer policy changes from Healthfirst, NC Medicaid - NCDHHS, and 27 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 99213 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 99213 on AAPC
Healthfirst is moving obstetric billing from the historical global obstetrical payment model to a service-level, encounter-based framework. Beginning June 1, 2026, routine prenatal visits for certain pregnancies must be reported separately using the appropriate E/M code with modifier TH. Starting January 1, 2027, global obstetrical package codes will no longer be recognized for reimbursement.
Effective November 1, 2026, Healthfirst bundles G2211 into the E/M service for HARP, Essential Plan and Qualified Health Plan members, and treats G0545, the listed counseling, screening and vision codes, and prolonged service codes 99415 through 99418 as inclusive to the associated E/M or preventive service for Medicaid Managed Care, Child Health Plus, HARP, Essential Plan and Qualified Health Plan members. Effective January 1, 2027, G0545 and the listed counseling, screening and vision codes are not separately reimbursable with an E/M or preventive medicine service for Medicare Advantage and CompleteCare (MAP) members, and CPT 99415 through 99418 are non-covered for those plans. Claims with G2211, G2212 or G0545 billed with an E/M service appended with modifier 25 will be denied, and G2211 is not separately reimbursable for Healthfirst Medicaid members age 21 and older.
NC Medicaid is transitioning to new AMA maternity CPT codes effective January 1, 2027. Starting September 1, 2026, providers must begin using E/M codes (99202-99215) with the TH modifier for prenatal/postpartum care when delivery is anticipated after 1/1/2027. All current maternity codes including global bundles will be deleted on 1/1/2027. Current codes may be used through 12/31/2026 for pregnancies completing before that date.
Effective November 1, 2026, Medi-Cal encourages obstetrical providers to submit claims for prenatal and postpartum care using E&M codes (99204, 99205, 99213, 99214, 99215) with modifier TH instead of global obstetric codes. This change anticipates the AMA's January 1, 2027 replacement of the global obstetric CPT code structure, allowing separate identification of antepartum, labor, delivery, and postpartum services. Claims must include appropriate gestational age ICD-10 codes (Z3A.00-49 for prenatal) or postpartum codes (O86-O92, Z39.0-2, F53.0-1).
Effective November 1, 2026, Medi-Cal encourages obstetrical providers to bill prenatal and postpartum care using E&M codes (99204, 99205, 99213, 99214, 99215) with modifier TH instead of global obstetric codes. This change aligns with upcoming AMA coding framework changes (effective January 1, 2027) that separately identify antepartum, labor, delivery, and postpartum services. Prenatal claims must include gestational age codes (Z3A.00-Z3A.49); postpartum claims must include relevant postpartum diagnosis codes (O86-O92, Z39.0-Z39.2, or F53.0-F53.1).
Highmark is implementing the AMA's new maternity care coding and billing model effective January 1, 2027. Providers must transition from submitting single global maternity claims to billing for services as they occur throughout pregnancy using E/M codes with TH modifier (starting October 1, 2026) and new CPT codes (starting January 1, 2027). Billing approach during the transition period (Oct 1 - Dec 31, 2026) depends on number of antepartum visits completed.
Effective September 1, 2026, MassHealth requires providers to transition maternity care billing for new patients to evaluation and management (E/M) codes with TH modifier instead of global maternity CPT codes (59425, 59426, etc.). Existing patients with first prenatal visits before September 1, 2026 continue using legacy codes; new patients after that date must use appropriate E/M codes (99202-99205 for new patients, 99211-99215 for established patients, plus telemedicine codes) based on medical decision-making level.
Blue Cross Blue Shield of North Dakota now requires modifier AF on E/M codes 99202-99215 for Medicaid Expansion claims when billed with a primary Behavioral Health diagnosis to receive the Behavioral Health fee schedule. Claims billed with modifier AF without a primary behavioral health diagnosis will be rejected as non-payable (provider liable). This requirement becomes effective for claims processed on or after August 17, 2026.
Priority Health published 15 billing policy updates effective July 23 and September 23, 2026, affecting multiple service lines including OMT, DME, oncology, sleep medicine, and vascular studies. Key changes include clarifications on modifier usage, supply limit calculations, coding guidelines, and medical necessity criteria. Billing teams must review and implement updates across multiple service categories to ensure accurate claim submission.
Humana Healthy Horizons Louisiana Medicaid now covers chiropractic services as an In Lieu of Services (ILOS) alternative for members 21+ with neuromusculoskeletal spine conditions. Up to 18 treatment sessions are covered annually without prior authorization; additional sessions require plan approval. Initial visits must include a documented treatment plan with care level, goals, and effectiveness measures. Spinal manipulation is limited to 5 regions per visit, with maximum 2 additional treatments (dry needling, electrical stimulation, manual therapy, etc.) allowed per date of service.
Unless otherwise noted, Utah Medicaid changes in July 2026 take effect July 1, 2026. Telehealth services require modifier 93 or 95 beginning October 1, 2026, and several behavioral health codes and revenue code reporting change in January 2027. Other changes cover provider revalidation and enrollment, dental claims moving from managed care to fee-for-service, custom tracheostomy tube billing, and behavioral health code rates.
This policy clarifies correct documentation and billing standards for interactive complexity add-on code +90785 and psychotherapy codes when billed with E/M services. Key changes emphasize that +90785 applies only to documented interactional barriers requiring active management (not emotional difficulty), psychotherapy requires minimum 16 minutes of face-to-face therapeutic work with specific clinical documentation, and E/M and psychotherapy time must be separately tracked and documented to avoid compliance violations.
Effective July 1, 2026, MO HealthNet will discontinue coverage for physical therapy, chiropractic therapy, and acupuncture services under the Complementary Health and Alternative to Chronic Pain Management Program. All pre-certifications for these services approved beyond July 1, 2026 will be closed as of June 30, 2026. Cognitive Behavioral Therapy (CBT) remains covered with specific code and precertification requirements.
Healthfirst's Obstetric Billing Guidelines policy (PO-RE-132v5) moves maternity billing from the global obstetrical payment model to service-level, encounter-based billing for certain pregnancies beginning June 1, 2026. Starting January 1, 2027, global obstetrical package codes are no longer recognized for reimbursement, and antepartum and postpartum services must be reported using E/M codes. Routine prenatal E/M visits require modifier TH, and claims that do not follow the coding and billing requirements, including the prenatal E/M and TH modifier requirements, may be denied or rejected.
Effective June 1, 2026, NYS Medicaid is transitioning from bundled global obstetric CPT codes to unbundled E/M codes with TH modifiers for prenatal services. All bundled obstetric codes (59400, 59425, 59426, 59510, 59610, 59618) will be deleted and unavailable on January 1, 2027. Billing teams must update systems, provider contracts, and documentation requirements to use E/M codes (99202-99205, 99211-99215, 99341-99350) with pregnancy-related O or Z ICD-10 codes and include CPT 0500F on initial prenatal visits.
Ambetter Health will no longer cover HCPCS add-on codes G2211 (complexity add-on for established patient relationships) and G2212 (prolonged E/M services) effective April 1, 2026. Billing teams must transition to standard CPT E/M codes (99202–99205, 99211–99215) for all Ambetter claims on or after this date.
Effective April 1, 2026, Ambetter Health will no longer cover HCPCS codes G2211 and G2212 (Medicare add-on codes for visit complexity and prolonged E/M services). Billing teams must transition to standard CPT E/M codes (99202–99205, 99211–99215) for all applicable visits.
Effective April 1, 2026, Ambetter Health will no longer cover HCPCS add-on codes G2211 (complexity add-on for established patient relationships) and G2212 (prolonged E/M services). Billing teams must stop submitting these codes for Ambetter claims and use only primary CPT E/M codes (99202–99215) instead.
Health Net will no longer accept or reimburse Medicare add-on codes G2211 and G2212 effective April 1, 2026. Providers must use standard E/M codes (99202-99205, 99211-99215) instead to reflect the level and duration of services provided.
Maryland Medicaid has updated coding guidelines for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), clarifying billing procedures for multiple encounters per day and specifying different trigger codes for MCO versus Fee-for-Service claims. The policy details specific submission requirements for somatic, mental health, substance abuse, and dental services.
Blue Cross of Idaho has updated its Risk Adjustment Accuracy (RAA) Program for 2026 performance metrics under Medicare Advantage value-based care arrangements. Participating providers must now track and meet specific targets for Annual Wellness Visit (AWV) rates and HCC Reconsideration rates, with performance measured quarterly (Q2) and year-end, using updated weighted calculations that determine performance levels 1-5.
For dates of service January 1, 2026 and forward, select primary care services under the HUSKY Health Primary Care Increased Payments Policy are reimbursed at 85% of the 2025 Medicare physician fee schedule. Services by advanced practice registered nurses (APRNs) and physician assistants (PAs) are reimbursed at 90% of the physician rates listed in the policy's fee table. Provider Bulletin 2026-14 supersedes the rate guidance in Provider Bulletin 2017-72, and there are no changes to eligibility, attestation, attestation validation, claims submission, or claims processing requirements.
Starting January 1, 2026, Florida Blue will no longer accept office E&M codes 99202-99215 with modifiers 93 or 95 for telemedicine services on commercial plans. Providers must instead use the new telemedicine-specific CPT codes 98000-98015 that became available in 2025.
NYS Medicaid fee-for-service reimbursement rates for physician, nurse practitioner, and midwife services are increasing, benchmarked to 90% of Medicare rates. Preventive medicine codes (99381-99387, 99391-99397) increase effective October 1, 2025, while office visits, emergency visits, immunizations, and select diagnostic codes increase effective April 1, 2026. Billing teams must update fee schedules across multiple NYS Medicaid fee schedule documents.
MassHealth updated billing requirements for annual behavioral health wellness examinations effective September 23, 2025. The policy provides specific CPT codes and modifiers for different provider types and settings, with no member cost-sharing required.
Effective September 1, 2025, MassHealth is implementing a bundled encounter rate for Behavioral Health Urgent Care (BHUC) centers. BHUCs must now bill using HCPCS code H2013 with modifiers HB (adult) or HA (child/adolescent), accompanied by zero-pay service codes indicating the type of mental health service provided. The GJ modifier for enhanced urgent care rates is being discontinued for BHUCs and non-BHUC mental health centers.
Effective September 1, 2025, managed care entities must pay behavioral health urgent care providers (BHUCs) one encounter bundle per patient per day instead of each individual service, billed as H2013 with modifier HB for adults or HA for children and adolescents, at no less than the MassHealth fee-for-service minimum rate for the bundle code. The services listed in Table 2 are included in the bundle and must be reported on the claim with a zero charge. The GJ modifier for urgent services is not allowed beginning September 1, 2025.
Maryland Medicaid has implemented enhanced reimbursement rates for eligible primary care providers effective August 1, 2025. The higher rates apply to evaluation and management codes 99202-99499 and G2211, with Managed Care Organizations required to pay these minimum rates to in-network PCPs.
Maryland Medicaid is implementing enhanced reimbursement rates for E&M codes 99202-99499 and G2211 for eligible primary care providers, effective August 1, 2025. This applies to MCO-designated PCPs, certain FFS providers, and behavioral health providers including psychiatrists and psychiatric nurse practitioners.
New Jersey Medicaid is increasing reimbursement rates for primary care services to 70% of Medicare rates, effective July 1, 2025. This applies to evaluation and management codes (99202-99499) and immunization administration codes, with managed care organizations required to use these as minimum payment rates.
Effective July 1, 2025, Arkansas Department of Human Services will no longer cover global OB codes unless beneficiaries have third-party liability insurance and/or Medicare. All OB services must be billed using itemized procedure codes (59409, 59425, 59426, 59514, 59612, 59620 for delivery/prenatal care) and postpartum visits must be billed as E&M codes with modifier TH. Eight previously bundled global OB codes are being terminated for non-TPL/non-Medicare beneficiaries.
Oscar's November 2026 provider newsletter bundles several changes for billing teams: taxonomy codes are now required on claims (billing provider on every claim, rendering taxonomy whenever a rendering NPI is listed), 2027 Preferred Drug List and formulary changes take effect January 1, 2027, reimbursement policy changes take effect December 1, 2026 (retirements) and February 1, 2027 (bilateral modifier LT/RT guidance, multiple procedure rules, E/M reorganization, new Preventive Medicine Services policy), and authorization requests for several EviCore specialty programs move to Availity Essentials on January 1, 2027. The taxonomy requirement is stated as an immediate action with no specific effective date given.
This Maryland Medicaid MCO policy clarifies billing requirements for resident-provided E/M services under the primary care exception using the GE modifier. Teaching physicians can bill for lower- and mid-level E/M services (99211-99213, 99202-99203) and specific preventive/telehealth codes when residents work independently, but visit level selection must be based on Medical Decision Making only (not time), and teaching physicians cannot bill level 4-5 office/outpatient visits.
Blue Cross of Idaho consolidated provider policies and clarified reimbursement for add-on code G2211 (E/M visit complexity code). G2211 is NOT reimbursable for Commercial, Connected Care Organization, and Qualified Health Plan products, but IS reimbursable for Medicare Advantage only when billed with valid E/M base codes (99202-99205, 99211-99215), documented medical necessity exists, and specific conditions are met. A new exception effective January 1, 2025 allows G2211 with modifier 25 on MA plans in specific cases per CMS CR 13705.
New Mexico Medicaid's EPSDT (Tot to Teen Healthcheck) well-child visit requirements call for a comprehensive, age-appropriate visit that includes medical history, nutrition screening, measurements, vision and hearing screening, developmental and behavioral screening, a physical examination, oral evaluation, immunizations per the AAP schedule, and anticipatory guidance. Children entering state custody must receive a comprehensive well-child visit within 30 days of entry, and all Medicaid-enrolled children must receive a blood lead level screening test at 12 and 24 months. Maternal depression screening during infant well-child visits is reimbursable under the infant's Medicaid ID.
The Connecticut Maternity Bundle pays eligible obstetric practices a monthly case rate for most maternity care in HUSKY Health, covering a perinatal episode from 280 days before delivery to 90 days after delivery, and year-end reconciliation against a target price is upside only. Doula services and lactation support are new covered services, and accountable providers that receive doula care add-on funding get $21 per member per month ($14 for doula services and $7 for lactation support) within the monthly case rate payment. Procedure codes on the case rate list zero pay once a maternity episode is triggered, and the claim detail shows EOB 9950 with CARC 245 and RARC M15.
Already effective October 1, 2026, with implementation on October 5, 2026, CMS Transmittal 13803 updates Chapter 9 of the Medicare Claims Processing Manual for Rural Health Clinic and FQHC claims. CMS permanently bypasses FISS reason codes 31836 and 31837 for Category II HCPCS codes and Care Coordination Services with status indicator M or E1, and it replaces the prior virtual communication and care management sections with new ones. The update also sets out FQHC specific payment codes G0466 through G0470 and revised telehealth billing instructions, and it replaces Transmittal 13772, which covered only RHC claims, by adding FQHCs (77X TOB).
Maryland Medicaid will now reimburse authorized SUD providers (PT 50) for pre-release Medication-Assisted Treatment (MAT) services delivered via telehealth to incarcerated individuals within 90 days of release as part of the Reentry SUD/SMI Program for Adults. Providers must be contracted with DPSCS, Medicaid-enrolled, and currently licensed. All services require pre-authorization and must use place of service code 09 with GT or UB modifiers.
Alabama Medicaid introduces a new $50 travel payment (CPT 99429) for EPSDT providers delivering screenings to justice-involved youth in carceral facilities, effective July 1, 2026. The payment is in addition to the existing $88 EPSDT screening rate, with a limit of two payments per calendar year per beneficiary. Providers must use POS code 09 and be enrolled with Specialty 560 to bill this service.
Connecticut Medicaid corrected an overpayment error for behavioral health add-on codes (90833, 90836, 90838) when billed with evaluation codes, taking back excess payments on April 15, 2026 remittances. Claims are now paying correct combo rates per the original 2012 guidelines.
Nevada Medicaid has clarified specific billing codes that pharmacists can use at FQHCs for various services including contraceptives, HIV prevention/treatment, substance abuse screening, and medication-assisted treatment. Some codes require system updates before they can be processed.
Maryland Medicaid clarifies that residents in GME programs with primary care exception can bill lower and mid-level E/M services (99202-99203, 99211-99213) using the GE modifier without teaching physician physical presence. Teaching physicians must still review care and can only use Medical Decision Making (not time) for visit level selection.
Effective January 1, 2026, Kansas Medicaid will require Certified Community Behavioral Health Clinics (CCBHC) to have a primary diagnosis within ICD-10 range F01-F99 (behavioral health conditions) when billing specific E/M codes. This applies only to Provider Type 11, Provider Specialty 121 facilities providing services that include T1040.
Connecticut Medicaid (HUSKY) is implementing a new J-code (J0013) for billing Spravato (esketamine nasal spray) effective January 1, 2026, replacing the previous S0013 code. The policy updates prior authorization requirements and clarifies billing procedures for both physician offices and outpatient hospitals administering this treatment for depression.
Performance Year 2 of the HUSKY Health Maternity Bundle Payment Program began January 1, 2026 and ends December 31, 2026, paying Accountable Providers monthly Case Rate payments for a subset of prenatal and postpartum services starting in the second trimester, while first trimester services are paid fee-for-service. Reconciliation is upside-only, so Accountable Providers may share up to 50% of savings when the actual total cost of care does not exceed the target price, and are not held financially responsible for costs above it.
Effective for dates of service on and after August 11, 2025, schools that provide school-based services can submit claims to ForwardHealth for an expanded set of procedure codes. The new codes cover psychological, counseling, social work, and mental and behavioral health services, therapy and audiology services, nursing and physician services, and dental services. Modifiers are no longer required on school-based services claims for those dates of service, although allowable modifiers are still accepted, and other claims submission requirements have not changed.
Blue Cross of Idaho updated FQHC billing requirements for Medicare Advantage patients, removing MMCP/IMP billing requirements and clarifying language for Chronic Care Management (CCM), Virtual Communication Services (VCS), Psychiatric Collaborative Care Model (CoCM), and telehealth services. FQHCs must continue using specific revenue codes and HCPCS codes for qualifying services under the CMS Prospective Payment System.
Blue Cross of Idaho revised billing requirements for Rural Health Centers (RHCs) under Medicare Advantage plans, removing MMCP/IMP language from previous policy versions. RHCs must continue using specific Type of Bill 71X with designated revenue codes and CPT/HCPCS codes for qualifying visits under the CMS prospective payment system.
Kansas Medicaid (KMAP) is increasing reimbursement rates for pediatrician office visit codes effective July 1, 2025. Nine common office visit CPT codes will have new higher payment rates, but only for providers with the specific Pediatrician specialty designation (31/345).
New Jersey NJ FamilyCare now provides enhanced reimbursement for pediatric primary care visits (well and sick visits) for children ages 0-3 at HealthySteps-certified sites. Billing teams must co-bill CPT code H0025 TL with eligible visit codes to receive the enhanced rate (minimum $15). HealthySteps sites must notify all MCOs within 30 days and only practices meeting HealthySteps model fidelity are eligible.
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