Do you need to use modifier 25 on both a wellness code and an Evaluation and Management (E/M) visit code on the same claim?

Modifier 25 Usage with Wellness and E/M Visit Codes

When billing both a wellness code and an E/M visit code on the same claim, you only need to append modifier 25 to the E/M code, not to the wellness code. 1

Proper Coding Approach

The American Academy of Pediatrics and other medical billing authorities provide clear guidance on this matter:

• Modifier 25 should be applied to the E/M service code (problem-oriented visit) when performed on the same day as a preventive service
• The preventive service code (wellness visit) does not require a modifier
• This approach indicates that a significant, separately identifiable E/M service was performed in addition to the preventive service 2, 1

Documentation Requirements

When billing both services on the same day, ensure:

• Separate documentation for both the preventive and problem-oriented components
• Clear medical necessity for the problem-oriented service
• Documentation supporting the complexity level of the E/M code
• Evidence that the problem-oriented service was significant and separately identifiable from the wellness visit 1

Billing Process Example

1. Bill the appropriate preventive service code (e.g., 99381-99397) for the wellness component
2. Add the appropriate E/M code (e.g., 99201-99215) with modifier 25 for the problem-oriented component
3. Document both services thoroughly to support medical necessity 1

Rationale and Importance

This coding approach is critical because:

• It represents an important window of opportunity for addressing problems during preventive visits 2
• It allows for same-day treatment of issues that would otherwise require another separate healthcare visit 2
• It reduces the risk of loss to follow-up when problems are identified during preventive visits 2

Common Pitfalls to Avoid

• Applying modifier 25 to both codes (unnecessary and incorrect)
• Insufficient documentation to support the separately identifiable nature of the E/M service
• Failing to document medical necessity for the problem-oriented service 1, 3

Financial Considerations

• Preventive services are typically covered at 100% under many insurance plans
• Problem-oriented services (with modifier 25) may be subject to copays, coinsurance, or deductibles
• The Office of Inspector General (OIG) closely reviews claims with modifier 25, making proper documentation essential 1, 3

Remember that accurate coding and proper modifier usage not only ensure appropriate reimbursement but also help avoid unwanted attention from government auditors who have specifically targeted modifier 25 usage for review 3.