This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.
Debunking the myth
Physicians are not prohibited from coding and billing for both preventive and problem-focused Evaluation and Management (E/M) services when they are performed during the same appointment.
Background
When a patient is seen for a physical or preventive/wellness visit—and also has acute complaints or chronic problems which require additional evaluation—some physicians encounter challenges when coding and billing for both services. There is confusion about whether it is permissible to bill for acute or chronic care, as well as the preventive service, in the same visit. Sometimes physicians are advised that they cannot bill for both services, other times they are told they can bill for both but only one will be paid, and sometimes there is patient pushback when they receive a billing statement with charges they were not anticipating.
Additional information
The Current Procedural Terminology (CPT®) guidelines provide clarification. If an abnormality is encountered or a preexisting problem is addressed in the process of performing a preventive/wellness visit, and the problem or abnormal finding is significant enough to require additional work to perform the key components of a problem-focused E/M service, then the appropriate office/outpatient E/M code should also be billed. Modifier-25 should be added to the office/outpatient code to indicate that a significant, separately identifiable E/M service was provided on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported. The significance of the problem addressed and the amount of time and medical decision-making required help determine how the services are most appropriately billed.
It is important to accurately and completely document all medically appropriate and necessary care performed during a patient encounter, and to bill for what is documented. Many physicians, usually motivated by a desire to avoid audits, tend to under-code for the work they have performed, resulting in significant amounts of uncompensated care. An additional E/M code should not be billed if the addressed problem/abnormality is insignificant or trivial and does not require additional work and the performance of the key components of a problem-focused E/M service.1
When billing Medicare, CMS requires that additional qualifying E/M services be billed separately from the preventive service. The CMS website states, “When you provide an annual wellness visit and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, we [Medicare] may pay for the additional service. Report the additional CPT code (99202–99205, 99211–99215) with modifier-25. That portion of the visit must be medically necessary and reasonable to treat the patient’s illness or injury, or to improve the functioning of a malformed body part.”2 Commercial payers, depending on the patient’s specific policy, may or may not cover the additional problem-focused E/M service billed at the same visit as the preventative service. Whether the services are being billed to a commercial payer or Medicare, using Modifier-25 properly will help ensure the charges eligible for payment are processed correctly.
Billing additional codes may affect the patient’s out-of-pocket financial responsibility for a visit. Physicians may choose to discuss this possibility with their patients at the time of service to help avoid confusion and frustration related to unexpected charges. Practice billing staff should also be familiar with the payers and their policies to minimize the risk of unanticipated charges.
Scenario
In an example provided in AMA’s “Reporting CPT Modifier 25” guidance, a mother raises concerns about her 3-year old son’s new symptoms—irritability and ear pulling—during a scheduled well-child visit. In addition to routine health maintenance (e.g., obtaining a comprehensive medical history, checking growth and blood pressure, performing an age-appropriate exam, assessing development, reviewing immunizations, and providing parenting guidance to the mother), the physician conducts an expanded evaluation based on the child’s reported symptoms. A diagnosis of acute right otitis media is made, and appropriate management, including antibiotic use and follow-up guidance, is discussed and documented.
Since the physician performed key components of a problem-oriented E/M service during a scheduled preventive visit—and the MDM level was beyond the usual services of the preventive medicine visit—the physician can bill the visit as both a preventive and problem-oriented E/M encounter by appending Modifier-25.
Takeaway
To ensure appropriate reimbursement and reduce administrative burden, physicians should append Modifier-25 when billing for both a preventive and problem-focused E/M service in the same appointment as long as the E/M service performed is significant, separately identifiable, and documented. Organizations should provide guidance to physician staff on the applicable scenarios wherein both services may be billed in the same encounter.
Resources
- 2023 AMA “Reporting CPT Modifier 25” CPT® Assistant Guidance (PDF). Accessed July 2025.
- CMS MLN Educational Tool: Medicare Wellness Visits. Accessed July 2025.
- 2018 Medical Economics article: “When an E/M code can be billed with a physical on the same day”. Accessed July 2025.
- 2021 American Academy of Family Physicians Journal FPM article: “How to Avoid Medicare annual wellness visit denials”. Accessed July 2025.
- 2022 American Academy of Family Physicians Journal FPM article: “Combining a Wellness Visit With a Problem-Oriented Visit: a Coding Guide”. Accessed July 2025.
- 2024 AMA STEPS Forward® Medicare Annual Wellness Visit Toolkit. Accessed July 2025.
AMA policy
- D-70.971 Uses and Abuses of CPT Modifier-25
- D-385.956 Opposition to Reduced Payment for the 25 Modifier
- H-70.910 Reporting Multiple Services Performed During a Single Patient Encounter
References
- American Medical Association. Reporting Modifier 25. CPT® Assistant (Online). 2023;33(11):1-12. https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf
- Centers for Medicare & Medicaid Services. MLN6775421 – Medicare Wellness Visits. CMS. 2025. Accessed July 10, 2025. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html#AWV
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Debunking Regulatory Myths overview
Visit the overview page for information on additional myths.
Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.
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