CPT 99402, in plain terms, covers Individual preventive medicine counseling or risk factor reduction, separate from a preventive exam, for approximately 30 minutes. CPT 99402 is referenced in 21 tracked payer policy changes from Anthem BCBS, BlueCross BlueShield of South Carolina, and 13 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 99402 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Official descriptor: CPT 99402 on AAPC
Effective January 1, 2027, HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid in Virginia) will discontinue reimbursement for 44 specific procedure codes to align with the Virginia Department of Medical Assistance Services (DMAS) fee schedule. The practice must stop billing these codes for dates of service on or after that date, as claims for discontinued codes will be denied or subject to adjustment and recovery.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 40 updated medical policies effective May 29, 2026. Most are routine annual reviews with no policy intent changes. Key billing updates include: new CPT codes 77062-77063 for breast cancer screening, replacement of CPT 99401-99402 with HCPCS S9943 for breastfeeding counseling, new compression pump CPT codes E0658/E0678-E0683 for lymphedema treatment, new CPT 0423U for pharmacogenetic testing, addition of HDR prostate brachytherapy as salvage therapy, new corneal collagen cross-linking products covered, and deletion of radiation therapy codes G6015-G6016.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 40 medical policy updates effective May 29, 2026. Key billing changes include: (1) CPT codes 77062 and 77063 added for breast cancer screening; (2) HCPCS code S9943 replaces CPT codes 99401/99402 for breastfeeding counseling; (3) Seven new E-series codes (E0658, E0678-E0683) added for compression pumps; (4) CPT code 0423U added for pharmacogenetic testing; (5) One new policy (CAM 404) for Transcranial Magnetic Stimulation; (6) CAM 80133 expanded to include HDR temporary prostate brachytherapy as salvage therapy; (7) CAM 80160 reorganized criteria for ECMO; (8) CAM 90328 expanded to include epithelium-on corneal collagen products.
Maryland Medicaid updated billing requirements for Community Violence Prevention (CVP) services effective April 1, 2026. CVP providers must now maintain a contractual affiliation with a trauma hospital (documented via letter in ePREP), bill initial encounters with specific place-of-service codes (19, 21, or 22), use CPT 99402 for all CVP services, and apply telehealth modifiers (GT for visual-audio, UB for audio-only) when applicable.
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.
Already effective July 1, 2026 for New York State Medicaid fee-for-service, and effective November 1, 2026 for Medicaid managed care plans, enhanced reimbursement applies to certain physical health services in OASAS, OMH and OPWDD certified outpatient clinics. Rates increase 20 percent for listed services in OASAS clinics, Article 31 MHOTRS clinics and Article 16 OPWDD clinics, and 20 percent for all services in Article 31 clinics for individuals eligible for the OPWDD waiver or enrolled in the TBI waiver. Services in OASAS Article 32 clinics for those individuals increase 50 percent.
Effective for dates of service on and after July 1, 2026, Medicaid covers a broader range of services furnished by enrolled pharmacists: ordering and administering qualified immunizing agents, ordering qualified laboratory tests (currently CLIA-waived tests for COVID-19, influenza or a respiratory infection collected by nasal or throat swab or finger prick), and counseling for and prescribing self-administered hormonal contraceptives. Implementation of this policy is contingent upon approval of a State Plan Amendment (SPA) by CMS.
BlueCross BlueShield of South Carolina updated 35 medical policies in May 2026, with key billing code changes for breast cancer screening and breastfeeding counseling, expanded coverage for lymphedema compression pumps, new salvage therapy coverage for prostate cancer, and introduction of a new Transcranial Magnetic Stimulation policy.
Maryland Medicaid updated billing requirements for Community Violence Prevention (CVP) services effective April 1, 2026. CVP providers must now use CPT code 99402 for both initial and follow-up services, with specific place of service codes (19, 21, or 22) for initial encounters and appropriate telehealth modifiers (GT for visual-audio, UB for audio-only) when applicable.
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, Delaware insurers must cover doula services for pregnant and birthing individuals under individual, small group, and large group fully insured policies. Coverage includes prenatal visits, postpartum visits, labor/birth attendance, and additional visits as clinically recommended. Doulas must be certified per Delaware DMMA requirements, and billing uses HCPCS codes T1032 and T1033, or preventive counseling codes 99401-99403 with diagnosis code Z391.
Oregon Health Authority is increasing Medicaid fee-for-service primary care rates by 2%, raising the conversion factor from $27.82 to $28.50. This affects evaluation and management codes, immunization administration codes, and health/behavior assessment codes.
Health Net California eliminated prior authorization requirements for FDA-approved HIV PrEP medications and all CDC-recommended integral services. Billing teams must use Z29.81 as the primary diagnosis code for all PrEP-related services to ensure proper coverage without cost-sharing.
CalViva Health has issued updated billing guidelines for HIV Pre-exposure Prophylaxis (PrEP) services. All PrEP medications and integral services must be covered without cost-sharing, and providers must use primary diagnosis code Z29.81 with specific CPT codes for proper billing to avoid payment delays.
Health plans must cover all FDA-approved HIV PrEP medications and integral services without cost sharing, prior authorization, or step therapy (except when therapeutic equivalents exist). Billing teams must use Z29.81 as the primary diagnosis code for all PrEP-related services and follow specific CPT coding guidelines for oral and injectable PrEP protocols.
Medical Mutual has issued updated coding guidance for Medicare Advantage patients requiring follow-up visits after hospitalizations and ED visits. The policy specifies exact CPT codes to use for documenting transitional care management, medication reconciliation, and outpatient follow-up visits to meet HEDIS quality measures.
BCBSAZ covers telehealth only as the member's benefit plan provides. Under the BlueCare Anywhere benefit, telehealth is covered when the Telehealth Services Administrator provides the service and determines the condition is appropriate, for a medical, therapy or psychiatry consultation. Under the in-network telehealth benefit, a service is covered when it would be covered in person and can be provided effectively by telehealth, through audio-visual services or limited audio-only services, and out-of-network non-emergency telehealth is not covered. The most recent review, dated 07/29/26, made no revisions.
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