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Increasing Your Rates: Using Modifier 25 to Convert Sick-Visits to Well-Visits

Maryland Physicians Care is dedicated to transforming the health of our community by keeping our children healthy. Your role as a provider is vital in increasing the rate of preventative and Well-Screenings among children.

Why is this important to you?

Increasing your Well-Visit ratio will impact your EPSDT and HEDIS Well-Child measures (W15, W34, and AWC) rates. As colder weather and flu season is upon us, it is an important opportunity to engage patients that fail to engage in routine Well-Care.

Why use modifiers?

Maryland Physicians Care will reimburse providers for a Sick-Visit and Well-Visit for the same date of service when provided to children 0-18 years of age. Documentation must support that the Well-Visit was significant and separately identifiable from the Sick-Visit.

What is Modifier 25?

Modifier 25 can be used when significant, separately identifiable, problem-oriented evaluation and management service is provided on (1) the same day as the preventive medicine service and/or (2) with the administration of immunizations. Please note that Modifier 25 is not to be used on preventive codes and needs to be billed using office or outpatient codes (99201-99215), and that these screenings bundle administration of immunizations. *Documentation must support the use of a modifier 25. See MD HealthChoice Provider Manual.

What additional documentation is needed?

Documentation must include a note indicating a visit to a PCP, the date when the Well-child visit occurred, and evidence of all of the following:

  • A health history
  • A physical development history
  • A mental development history
  • A physical exam
  • Health education/anticipatory guidance

Thank you for your continued care and for our most vulnerable populations. If you have any questions regarding Well-Care or the use of Modifier 25, please call Customer Service at 1-800-953-8854.

Note: [1] Maryland Physicians Care is not directing the providers which E/M sick code to use. The E/M codes are based on the level of complexity, the examination, and medical decision making involved.


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