MedicaidBilling CodesHigh impact
20-611 Clarify the Use of Modifier 25 and CPT Code 99211
Health Net·CA·Reimbursement
We identified it
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.
Action Required
Immediately: Billing team must update coding practices to only use modifier 25 with CPT 99211 when significant, separately identifiable E/M services are provided. Ensure all applicable diagnosis codes are assigned to support the need for additional E/M services. Stop billing CPT 99211 separately with vaccine administration codes 90465-90474 and G0008-G0010. Providers must submit supporting documentation with original claims using modifier 25. Update billing software rules and staff training to prevent inappropriate use of these codes.