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20-612 Clarify the Use of Modifier 25 and CPT Code 99211
Act
immediately
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
CalViva Health/Health Net clarified proper use of CPT code 99211 and modifier 25 for Medi-Cal patients in Fresno, Kings, and Madera counties due to increased claim denials. Providers must ensure proper documentation and appropriate diagnosis codes when billing these services together.
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What to do
immediately · 3 steps
01Billing team must review all claims using CPT 99211 with modifier 25 for Medi-Cal patients in Fresno, Kings, and Madera counties.
02Ensure diagnosis codes indicate need for separate E/M services and submit supporting documentation with original claims.
03Providers must document face-to-face encounters and avoid billing 99211 with vaccine administration codes 90465-90474 and G0008-G0010 unless service is separate and significant.
Codes mentioned
992119046590466904679046890471904729047390474G0008G0009G0010
Original notice
20-612 Clarify the Use of Modifier 25 and CPT Code 99211
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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