Skip to Main Content

20-611 Clarify the Use of Modifier 25 and CPT Code 99211

Date: 08/13/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.

Check how to avoid denials and when to indicate the need for added E/M service

Due to claim denials in Health Net’s Medi-Cal counties regarding the use of CPT code 99211 and the overutilization of modifier 25, Health Net has determined the need for a reminder when billing code 99211 and using modifier 25.

A significant, separately identifiable Evaluation and Management (E/M) service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

If claim history or assigned diagnosis codes do not indicate that significant, separately identifiable services were performed, Health Net covers the primary procedure or other service and denies the secondary E/M billed with modifier 25.

To avoid incorrect denials, providers should assign all applicable diagnosis codes that indicate the need for additional E/M services.

Modifier 25 should only be used to indicate that a significant, separately identifiable E/M service is provided by the same physician on the same day of the procedure or other service.

Documentation that supports the use of modifier 25 should be submitted with the original claim. If Health Net requests supporting medical documentation to prove medical necessity, the additional information on the contested claim is required within 365 days from receipt of Health Net’s decision.

The provider receives a denial determination on their remittance advice (RA) if the claims documentation is insufficient to support billing modifier 25. The provider may submit an appeal or reconsideration request as outlined in the Medi-Cal provider operations manuals.

Appropriate use of CPT code 99211

The Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) says code 99211 is intended for an office or other outpatient visit for E/M of an established patient that may not require the presence of a physician or other qualified health care provider.

Appropriate use of code 99211 includes:

  • The services must be for E/M.
  • The patient must be established, not new.
  • The services must be separated from other services performed on the same day.
  • The provider must be face to face with the member, not on the telephone.

Code 99211 cannot be reported separately with vaccine administration HCPCS/CPT codes 90465-90474 and G0008-G0010.

Only use code 99211 when the E/M service exceeds those services included in the vaccine administration codes and the:

  • Service is medically necessary.
  • Service must be separate and significant from the vaccine administration.

Other E/M CPT codes can be reported separately for a vaccine administration code if the E/M service is significant and separately identifiable, in which case the E/M CPT code may be reported with modifier 25.

When not to use CPT code 99211

It is not recommended to reimburse for a non-physician (such as a nursing visit) E/M service (99211) in conjunction with the following services:

  • chemotherapy administration
  • maintenance and filling of implantable pump or reservoir
  • allergy immunotherapy
  • therapeutic phlebotomy
  • vaccination/immunizations and administration
  • therapeutic, prophylactic or diagnostic injections
  • collection of blood/specimen (venipuncture)

Additional information

Use one of the two options below to access the provider operations manuals – in order to access claims or appeals details – in the Provider Library.

If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center within 60 days at 1-800-675-6110.



Last Updated: 08/12/2020