Can a modifier 25 be added to 99396?
Asked by: Rupert Beer | Last update: June 19, 2025Score: 4.9/5 (51 votes)
Can 99396 be billed with a 25 modifier?
Modifier 25 plays a critical role in accurately billing CPT Code 99396 for preventive visits that include problem-oriented services. With this modifier, primary care providers can bill for both the preventive visit and any additional problem-oriented service provided.
When not to use modifier 25?
Modifier 25 should not be used when: ❌ The sole purpose of the encounter is for the procedure (e.g., lesion removal), and there is no documented medical necessity for a separate E/M service.
Can you add a 25 modifier to G0439?
Along with HCPCS G0438 or HCPCS G0439, CPT code modifier -25 must be appended to the medically necessary E&M service. CPT guidelines define the -25 modifier as "Significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service."
Does modifier 25 go on 99497?
Not typically. However, payers may require modifier 25 on the code for the office E/M service to signify that a significant and separately identifiable office E/M service was provided in addition to the advance care planning (CPT codes 99497 and 99498).
Decoding Modifier 25 in Medical Billing
How do you add modifier 25?
Modifier 25 should be appended to the office or other outpatient visit code to indicate that a significant, separately identifiable E/M service was provided on the same date as the preventive medicine E/M service, and the appropriate preventive medicine E/M service is additionally reported without a modifier.
How to bill 99396?
You document both the problem-oriented and the preventive components of the encounter in detail. You should submit 99396, “Periodic comprehensive preventive medicine ..., established patient; 40-64 years” and ICD-9 code V70.
What is the CMS rule for modifier 25?
Use modifier 25 (same-day significant, separately identifiable E/M service) on the claim when you report critical care services unrelated to the service or procedure that you perform on the same day. You must also document the medical record with the relevant criteria for the respective E/M service you're reporting.
Can G0439 and 99396 be billed together?
Correct you can only bill one or the other (medicare annual wellness or a preventative examination).
Does 99497 need a 33 modifier?
Yes. Advance care planning is a preventive service only when provided in conjunction with an annual wellness visit and reported with modifier 33 attached to the advance care planning code (e.g., 99497-33).
Can modifier 25 be used with G0463?
You may need a -25 modifier on G0463 if the other services performed have a status indicator of S, T, or V.
Can you bill an AWV and E&M together?
The CMS website states “When you provide an annual wellness visit and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, Medicare may pay the additional service. Report the additional CPT code with Modifier-25.
Which of the following is true about attaching modifier 25?
Modifier 25 can only be attached to an E/M code. The E/M service must be significant and clearly separate. Both an E/M code and a procedure code must be submitted by the same physician on the same day as the procedure.
What is modifier 25 not used for?
Do not use modifier 25 when billing for services performed during a post-operative period if related to the previous surgery. Related follow-up examinations by the same provider during the global period of a previous procedure are included in that procedure's global surgical package.
Can you bill a 99396 to Medicare?
Original (traditional) Medicare does not cover CPT codes 99381-99397, because Medicare has its own wellness visits with their own “G” codes and requirements. As mentioned, some Medicare Advantage plans do cover the preventive medicine CPT codes in addition to Medicare wellness visits.
What is the modifier 25 for AWV?
Coding and Billing a Medicare AWV
Physicians must append modifier -25 (significant, separately identifiable service) to the medically necessary E/M service, e.g. 99213-25, to be paid for both services.
Can you add modifier 25 to 99396?
In this case, you may submit codes for both a preventive service (such as 99396) and a regular office visit (such as 99213) by attaching -25 to the office-visit code.
Can I use modifier 25 on a preventive visit?
This code can help you to get reimbursed for the extra work you do at certain visits. Many times a patient's “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more.
How to bill Medicare for an annual gyn exam?
- G0403 for the Initial Preventive Physical Exam (IPPE).
- G0438 for the first Annual Wellness Visit (AWV).
- G0439 for subsequent AWVs.
- G0101 for cervical or vaginal cancer screening and clinical breast exams.
Can you add modifier 25 to 99214?
Yes, you can add modifier 25 to CPT code 99214 if a significant, separately identifiable E/M service is performed on the same day as another procedure.
Does 99213 need a modifier 25?
If the E/M is not bundled into the stress test, then the Cardiologist's coder can use modifier 25 to indicate that these two services were separate and significant: 99213-25, 93015.
Does modifier 25 or 95 go first?
Since both modifier 25 and 95 can impact payment, list modifier 25 first.
Can 99396 be billed as telehealth?
Comprehensive prevention family planning visits are also covered via telemedicine/telehealth, billed with an FP modifier: CPT® 99384, 99385, 99386, 99394, 99395, 99396, 99401. Comprehensive prevention family planning visits will continue to be limited to once every 365 days.
Can you bill 99396 and G0439 together?
Don't bill CPT codes 99381-99397 (comprehensive preventive medicine evaluation and management services) for Medicare services covered by HCPCS codes G0402, G0438, and G0439.
What is the difference between 99396 and 99395?
99395: preventive care for established patients ages 18 through 39. 99396: preventive care for established patients ages 40 through 64.