11/6/25

CPT 98016 cannot be used to deliver normal lab results to patients over the phone. It can only be used if the patient initiates a call would it result in billable provider time. Please see additional guidance below:

98016 cannot be used for provider initiated calls related to labs, previous visits.

Code 98016 is reported for established patients only. The service is patient-initiated and intended to evaluate whether a more extensive visit type is required (eg, an office or other outpatient E/M service [99212, 99213, 99214, 99215]). Video technology is not required. 

Code 98016 describes a service of shorter duration than the audio-only services and has other restrictions that are related to the intended use as a “virtual check-in” or triage to determine if another E/M service is necessary. When the patient-initiated check-in leads to an E/M service on the same calendar date, and when time is used to select the level of that E/M service, the time from 98016 may be added to the time of the E/M service for total time on the date of the encounter.

If the patient is scheduled for a telemedicine visit then this is billed with EM.  Documentation will need to include that the patient consented to telemedicine visit and how this visit was conducted, phone, video etc

7/11/25

Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

Use modifier EP or TS with appropriate exam codes in the table below.

• Modifier EP indicates a normal, routine screening.

• Modifier TS indicates that a referral or follow-up services are recommended. When using modifier TS, link the most current diagnosis code(s) that reflects the condition requiring follow-up on the billing claim.These should come after the encounter code (e.g., Z00.121).

• Modifier 25 must be used with non-preventive medicine Evaluation and Management (E&M) services (e.g., codes 99212-99215) when reported in conjunction with vaccine administration when the E&M is significant and separately identifiable. Continue to use EP and TS modifiers as well. 

4/8/25

ICD Exclusion Notes:

An Excludes1 note means that if a patient has a specific diagnosis which includes an Excludes 1 note, any ICD codes specified in that note should not be reported in conjunction with that specific diagnosis.

An Excludes2 note means that if a patient has a specific diagnosis which includes an Excludes 2 note, any ICD codes specified in that note are able to be reported in conjunction with that specific diagnosis.

Example:

ICD E61.1 -Iron deficiency

Excludes1: iron deficiency anemia (D50.-)

Modifier 25

Modfier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other QualifiedHealthcare Professional on the Same Day of the Procedure or Other Service

Lay Term: Append modifier 25 to an E/M service when the provider renders an E/M to the patient on the same day as another service or procedure.

Modifier Explanation: The medical documentation has to justify performing the separate E/M service. The patient’s condition may warrant the same provider performing a separate E/M service and another service or procedure on the same day.

A provider may also render two E/M services to the same patient on the same day. Append modifier 25 to the second E/M service to prove that it was separate from the first E/M.

Modifier 59 - Distinct Procedural Service

Lay Term: Append modifier 59 to identify a procedure that is distinct or independent from other non–E/M services that the provider performs on the same day.

Modifier Explanation: Modifier 59 applies to procedures or services not typically reported together but are appropriate in specific situations. Modifier 59 tells the payer that the same provider does not ordinarily perform one procedure with another procedure for the same patient, on the same day. The procedures would not normally be reported together.

Append modifier 59 only if there is no more appropriate modifier to explain the circumstances. Documentation must support the use of the modifier.

Do not append modifier 59 to E/M services.

Modifier SL - State supplied vaccine

Lay Term: Append modifier SL to vaccine codes that a state supplies and a provider administers at no cost to eligible individuals.

Modifier Explanation: Each state provides some vaccines free of cost. Use modifier SL with immunization procedure codes to identify those immunization materials obtained from the state Department of Health to identify that the vaccine itself was obtained at no cost to the provider or patient.

2/7/25

Billing Preventive Visits with Evaluation and Management Services

Official CPT Guideline: “If an illness or abnormality is discovered, or a preexisting problem is addressed, in the process of performing the preventive medicine service, and if the illness, abnormality, or problem is significant enough to require additional work to perform the components of a problem-oriented evaluation and management (E/M) service (ie, using medical decision making or time spent), the appropriate office or other outpatient service code (99202–99215) should be reported in addition to the preventive medicine service code.

An insignificant or trivial illness, abnormality, or problem encountered in the process of performing the preventive medicine service should not be separately reported.”

►When it’s appropriate to report both CPTs append modifier 25 to the E/M service code. 

Example: 99392 and 99213-25

►Link the specific diagnosis for the problem being addressed to the E/M code. 

Example: 99213-25 w/ H65.01

►Link Z00.121 or Z00.129 to the well child visit depending on the circumstances.

Example: 99392 w/ Z00.121

It’s important to note the coding exclusions with certain ICD-10 codes when selecting diagnosis codes. These will outline which additional codes are not permitted to be reported together. Denials for these are commonly seen when ICD combo codes are available or when symptom codes are directly related to a more specific diagnosis.  An example of common codes that result in denials when paired on the same claim: 

• ICD J30.9, Allergic rhinitis unspecified being reported with J45.909, Unspecified asthma, uncomplicated.