CPT 99215, in plain terms, covers Office or outpatient visit for an established patient with high medical decision making or at least 40 minutes of total time on the date of the encounter. Time past 54 minutes may support prolonged service billing. CPT 99215 is referenced in 50 tracked payer policy changes from Healthfirst, NC Medicaid - NCDHHS, and 26 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 99215 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 99215 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.
Connecticut Medicaid requires antepartum visits to be billed with the E/M code that matches the visit type and location, with modifier TH on the detail line, for dates of service from September 1, 2026. FQHCs and family planning clinics keep their current antepartum billing through December 31, 2026, and new labor and delivery codes take effect January 1, 2027, with guidance still to come.
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.
CareSource Ohio Medicaid is implementing strict concurrent billing restrictions on psychotherapy add-on codes (90833, 90836, 90838) with high-level E/M services (99204, 99205, 99214, 99215). When billed together on the same date by the same provider, psychotherapy add-ons will be denied and only the E/M will be reimbursed. Providers must now document separate start/stop times, non-overlapping clinical effort, and ensure E/M levels are based on medical decision-making rather than time when billing these combinations.
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.
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.
KMAP updated Spravato® (esketamine intranasal) coverage and billing guidance, establishing that the drug is covered through pharmacy or medical claims. Effective January 1, 2026, the billing code for Spravato® changed from S0013 to J0013. Observation time is billed using 99215-U1 (first 54 minutes) and G2212-U1 (additional 15-minute increments), with G2212-U1 requiring a corresponding 99215-U1 on the same claim. Providers must establish written policies for delegating observation time to registered nurses and may only bill through specified provider types (Advance Practice Nurses/Psychiatric Nurse Practitioners, Mental Health Providers/CMHCs, and Physicians/Psychiatrists).
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.
Connecticut Medicaid has implemented new billing procedures for Children's Mental Health Urgent Crisis Centers serving children 18 and younger, effective October 1, 2025. The policy establishes specific billing codes (E&M visits, psychiatric evaluations, and crisis intervention) with important restrictions that E&M codes cannot be billed concurrently with psychiatric evaluation codes.
Cigna Healthcare will implement a new reimbursement policy (R49) on October 1, 2025, to review high-level E/M office visit claims for billing and coding accuracy. Claims with CPT codes 99204-99205, 99214-99215, and 99244-99245 will be subject to enhanced scrutiny to ensure compliance with AMA E/M guidelines.
Cigna Healthcare implemented a new reimbursement policy (R49) that automatically adjusts high-level E/M codes to lower levels for providers identified as having coding patterns inconsistent with diagnosis complexity. Claims are paid at the adjusted level but providers can request reconsideration with clinical documentation.
This is a monthly summary of all Cigna Healthcare policy updates published in November 2025, including a new E/M reimbursement policy (R49) that reviews high-level evaluation and management codes for accuracy, effective October 1, 2025. The summary also covers changes to prior authorization processes, portal enhancements, and various administrative updates.
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.
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.
Effective January 1, 2026, the HCPCS codes J1442, Q5125, J2506, Q5111, Q5127, J9312, Q5101, Q5108, Q5122 and Q5130 are added to the physician-administered drug (PAD) list that requires prior authorization (PA). Effective January 1, 2026, outpatient providers can bill transitions of care codes 99495 and 99496 in place of E/M codes 99214 and 99215 for follow-up visits within 14 days of discharge from inpatient or observation-level care. Claims billed with 2026 HCPCS procedure codes may suspend for EOB 0000 beginning January 1, 2026, and all codes must be reviewed for medical necessity, prior authorization coverage standards and rates before they are reimbursable.
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.
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.
South Dakota Medicaid is changing the HCPCS code for Esketamine (Spravato) nasal spray billing from S0013 to J0013 effective January 1, 2026. The policy clarifies specific E/M codes and add-on codes for associated professional services and observation time.
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.
Connecticut Medicaid has updated the reimbursement rate for crisis intervention services (H2011) at Children's Mental Health Urgent Crisis Centers, effective October 1, 2025. Claims with higher billed amounts than the new allowed rate will be retroactively adjusted in January 2026.
This is a summary compilation of September 2025 Provider Newsroom articles covering various updates including new E&M reimbursement policy R49 effective October 1, portal access changes, physical therapy site-of-care reviews, and clinical guidance on vaccines, cancer screening, and medication management.
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