What is the modifier 25 with a wellness visit?
Asked by: Ms. Lilla Baumbach MD | Last update: October 20, 2025Score: 4.9/5 (15 votes)
What is the modifier 25 for annual wellness visit?
What is modifier 25? Modifier 25 is a way to identify a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service,” according to the CPT 2024 code set.
What is the modifier for a wellness visit?
Coding and Billing a Medicare AWV
It is important that the elements of the AWV not be replicated in the medically necessary service. 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.
What is the 25 modifier used for?
The Current Procedural Terminology (CPT) definition of Modifier 25 is as follows: Modifier 25 – this Modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional.
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.
MEDICAL CODING MODIFIER 25 - Compliantly bill an E&M and separate service on the same date
Can you use modifier 25 with 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."
Can you do AWV and office visit the same day?
Yes, you can do an AWV and Chronic Visit E/M the same day. Provider can either complete 2 separate notes or just 1 note but it must be able to support both visits.
What are the new guidelines for modifier 25?
Do not use modifier 25 by a physician other than the physician performing the procedure or physician of the same specialty in the same group practice. Do not use modifier 25 when documentation does not support a significant, separately identifiable E/M service.
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.
When to use modifier 25 vs 59?
Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”
How do you bill a wellness visit?
The CPT codes for Annual Wellness Visits are G0438 for the initial visit and G0439 for subsequent visits. These codes are used to bill Medicare for comprehensive wellness assessments and personalized prevention plans.
What is not included in a wellness visit?
Your insurance for your annual wellness visit does not cover any discussion, treatment or prescription of medications for chronic illnesses or conditions, such as high blood pressure, high cholesterol or diabetes. In this instance as well, you will be charged a copay and/or a deductible.
What is the code for a wellness visit?
At ChartSpan, we provide eligibility checks for G0438 and G0439 — the core codes for Annual Wellness Visits.
What is the difference between a physical and an annual wellness visit?
While a physical includes a full examination and a wellness evaluation, an Annual Wellness Visits focuses solely on a patient's answers to a health risk assessment. It does not typically include any lab work or tests requiring physical contact.
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 Medicare pay for wellness visits?
With Medicare Part B, you can get a wellness visit once a year at no cost to you. Check to make sure the doctor or nurse accepts Medicare when you schedule your appointment.
What is modifier 25 example?
Modifier 25 is appended to indicate that a significant, separately identifiable E/M service was performed by the same physician or other QHP on the same date. A 25-year-old female (new patient) with a soft tissue breast lesion is referred to the surgeon by her primary care physician.
How do you know if its 99213 or 99214?
The primary difference between CPT code 99213 and 99214 lies in the complexity and time involved. While 99213 is for a low level of medical decision-making, 99214 is used for moderate complexity, requiring a higher level of medical decision-making and more extensive history and examination.
Can you put a 25 modifier on 99396?
By appending modifier 25 to the preventive visit code (99396), the provider can accurately report both services and receive appropriate reimbursement for each. Utilizing modifier 25 correctly is crucial to ensure accurate billing and reimbursement for preventive visits that include problem-oriented services.
Can you bill an office visit and hospital visit on the same day?
CPT Codes 99221-99223, 99231-99236, 99238 & 99239
MACs pay both visits if you see a patient in the office on 1 day, and they're admitted to the hospital as an inpatient or get observation care on the next day.
What is the CPT code for prolonged visit?
CPT code 99417 (Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time) is now allowed to be billed with 99245, 99345 and 99350.
Can I bill an office visit with an AWV?
When you provide an AWV and a significant, separately identifiable, medically necessary evaluation and management (E/M) service, we may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier 25.
What is the difference between a routine visit and a wellness visit?
So, while a routine check-up is like a health status update, an annual wellness visit is a strategic planning session for your health. Both are vital for your well-being—one for staying on top of immediate health concerns and the other for preventing potential future issues.
Can you bill 99395 and 99213 together?
can be used 99213 with 99395 at the same visit? Absolutely! You would use the modifier -25 on the 99213. Look at the Preventive Medicine section in CPT® and this is outlined in the narrative explanation prior to the actual listing of codes.