MedicaidDocumentationHigh impact
20-612 Clarify the Use of Modifier 25 and CPT Code 99211
Health Net·CA·Reimbursement
We identified it
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.
Action Required
Immediately: Billing team must review all claims using CPT 99211 with modifier 25 for Medi-Cal patients in Fresno, Kings, and Madera counties. Ensure diagnosis codes indicate need for separate E/M services and submit supporting documentation with original claims. Providers 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.