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20-611 Clarify the Use of Modifier 25 and CPT Code 99211
Act
immediately
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Health Net Medi-Cal is clarifying proper use of CPT code 99211 and modifier 25 due to increased claim denials. Providers must ensure modifier 25 is only used for significant, separately identifiable E/M services with proper documentation, and CPT 99211 cannot be billed separately with vaccine administration codes.
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What to do
immediately · 5 steps
01Billing team must update coding practices to only use modifier 25 with CPT 99211 when significant, separately identifiable E/M services are provided.
02Ensure all applicable diagnosis codes are assigned to support the need for additional E/M services.
03Stop billing CPT 99211 separately with vaccine administration codes 90465-90474 and G0008-G0010.
04Providers must submit supporting documentation with original claims using modifier 25.
05Update billing software rules and staff training to prevent inappropriate use of these codes.
Codes mentioned
992119046590466904679046890471904729047390474G0008G0009G0010
Original notice
20-611 Clarify the Use of Modifier 25 and CPT Code 99211
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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