Internal medicine modifiers: 25, 59, 24, and telehealth modifiers explained.
Internal medicine's modifier errors don't come from equipment ownership splits the way a cardiology or imaging practice's do — they come from stacking multiple billable services onto the same visit and the same code family. A preventive AWV lands on the same day as a sick visit, an EKG or an injection rides along with the E/M that ordered it, and a telehealth encounter now has to declare its own delivery format on the claim before it's even adjudicated. Four modifiers carry that weight in this specialty: 25, 59 and the X-modifiers, 24, and the telehealth trio 95/93/FQ. See our full internal medicine coding pillar for the rest of the specialty's billing rules — this guide covers each modifier with the specific denial pattern it triggers, not just the definition.
Key takeaways
- Modifier 25 on an AWV-plus-sick-visit is internal medicine's single highest-volume modifier use case. The failure point is almost never the modifier itself — it's preventive content bleeding into the problem visit's documentation, or vice versa.
- Modifier 59 rarely applies to the EKG family the way practices assume. Billing more than one of 93000/93005/93010 for a single tracing is a code-selection error, not a bundling edit a modifier can override.
- Modifier 24 is genuinely rare in general internal medicine — it only fires when an IM physician sees a patient during a different provider's post-op global period for something unrelated, and it's frequently omitted because the visit "doesn't feel surgical."
- Telehealth modifiers have to match the actual delivery format and the place-of-service code, not just be appended by habit. A mismatch between 93/95 and POS is an internally inconsistent claim that denies regardless of whether the visit itself was appropriate.
Why modifiers carry different weight here than in a procedural specialty
A cardiology or radiology practice leans on modifiers to split a single study into professional and technical components. Internal medicine doesn't do that kind of splitting at volume — its modifier load instead comes from service-stacking: a preventive code and a problem-oriented E/M on the same date, a diagnostic test or an injection riding alongside the visit that prompted it, and a delivery-format declaration on every telehealth claim. The modifier is the only thing on the claim that tells the payer which situation actually happened, and IM's high patient volume on 99213/99214-level visits means these situations recur daily, not occasionally.
Modifier 25: AWV plus a problem visit, and the documentation split payers actually check
Combining an Annual Wellness Visit with a same-day problem-oriented E/M is common, billable, and the highest-volume modifier 25 scenario in the specialty — a Medicare patient scheduled for G0438 or G0439 mentions a knee that's been bothering them, or comes in with a blood pressure reading that needs a medication adjustment, and the physician reasonably handles both in one visit. The modifier itself is straightforward to append. What actually decides whether the claim survives is whether the two services are documented as genuinely separate work, not just two different codes on the same date.
The AWV's components — the health risk assessment, the cognitive screen, the functional status review, the personalized prevention plan — can't double as the E/M's history or medical decision making. And the reverse is just as true: if the physician manages a hypertension medication adjustment during the same encounter, that management needs its own assessment-and-plan content, distinct from the AWV's prevention plan, with its own MDM elements documented on their own terms.
- AWV note: HRA, cognitive screen, and prevention plan documented under their own heading.
- Problem visit note: separate HPI, exam findings, and MDM for the specific complaint (e.g., knee pain — onset, exam, imaging order, plan).
- Diagnosis pointers reflect the actual split — a wellness Z-code on the AWV line, the specific problem code on the E/M line.
- The chronic conditions reviewed in the AWV's risk assessment are restated as the E/M's entire MDM, with no distinct new content.
- Both claim lines carry the same diagnosis code with no differentiating detail for the payer's system to key on.
- The problem visit reads as a continuation of the AWV rather than a separate, billable encounter.
Before submitting, run the strip test: remove the AWV content from the note entirely and ask whether what remains still reads as a complete, billable E/M on its own — its own history, its own exam or data elements, its own MDM. If it doesn't stand alone, modifier 25 doesn't fix that; the note does. Full HRA component checklist and AWV sequencing rules are in our Annual Wellness Visit billing guide (G0402, G0438, G0439).
Modifier 59 and the X-modifiers: EKG, injections, and other same-day procedures
These override an NCCI bundling edit — but only where the edit's modifier indicator allows it at all. An indicator of 0 means no modifier changes the outcome; an indicator of 1 means an NCCI-associated modifier (59, or the more specific XE/XS/XP/XU) can bypass the edit, but only where the record actually shows the second service was distinct. The full indicator logic and internal medicine's specific bundling collisions — EKG, spirometry, injection administration — are covered end to end in our NCCI edits and bundling guide for internal medicine; this section covers how the modifiers themselves get misapplied.
The EKG family is the case practices get wrong most often, and it usually isn't a modifier-59 situation at all. 93000 (global tracing plus interpretation), 93005 (tracing only), and 93010 (interpretation only) are mutually exclusive for a single EKG performed once on a single date. Billing two of the three — say, 93000 and then 93010 again because a second physician also reviewed the same tracing — isn't a bundling edit a modifier clears; it's billing the same test twice under different code language. The scenario where 59 or an X-modifier genuinely applies is a second, separately medically necessary tracing performed later the same visit — a patient who develops new chest pain mid-encounter and gets a second EKG. Even then, if the same physician performs the repeat, modifier 76 (repeat procedure, same physician) is usually the more accurate choice than 59, since it's a true repeat of the identical service rather than a distinct one.
Injection administration (96372 and similar) against the same-day E/M is the more common real-world 25-versus-59 confusion, and the modifier belongs on the E/M, not on the injection code. NCCI treats the minimal evaluative work inherent to giving an injection — confirming the drug, route, and patient tolerance — as bundled into 96372 itself; it doesn't independently support a separately billed E/M. Where a genuinely separate, billable E/M did happen — a physician examines and diagnoses cellulitis, then has staff administer an IM antibiotic for it — the E/M is billed with modifier 25 attached to the E/M code, and 96372 is billed on its own line with no 59 needed, because the two services aren't in an NCCI conflict with each other; the conflict, where one exists, is between the E/M and the injection's built-in evaluative component.
Before appending 59 or an X-modifier anywhere in internal medicine, ask which problem you're actually solving. If two component codes describe the same single test (the EKG family), the fix is billing the correct single code, not a modifier. If a procedure's built-in evaluative work is being confused with a separate E/M (injection administration), the modifier belongs on the E/M, not the procedure. Reaching for 59 as a default "make it pass" move on either pattern is one of the more reliably audited habits in outpatient billing, because the append rate is easy for a payer to track across a practice's whole claim history.
Modifier 24: unrelated E/M during another provider's global period
Modifier 24 covers a significant, separately identifiable E/M performed by the same physician during the post-operative global period of a procedure — and it's genuinely uncommon in general internal medicine, since the specialty performs little major surgery itself. Where it shows up is when an IM physician sees a patient during a different provider's global period — most often a surgeon's — for something that has nothing to do with the surgery.
- Example: a patient is three weeks into a surgeon's 90-day global period following a hip replacement. The patient's IM physician sees them for a scheduled hypertension follow-up and a medication adjustment — unrelated to the hip procedure, and billable with modifier 24 attached to the E/M.
- The note has to document why the visit is unrelated to the recent procedure, not just that it happened during the window — a payer's system flags the encounter by date range and needs the record to justify the modifier if reviewed.
- The modifier is omitted entirely because the visit "isn't related to surgery" in the physician's own thinking — but the claims system still needs modifier 24 to separate the encounter from the surgeon's global period, or it denies as bundled into someone else's procedure.
- Confusing 24 (during a global period, unrelated reason) with 25 (same day as a minor procedure) — the two solve different timing problems and aren't interchangeable.
Because this scenario depends on knowing another provider's global period dates, it's worth confirming at intake for any patient with a recent surgical history rather than discovering the conflict after a denial. A quick eligibility or claims-history check that surfaces recent major procedures is cheaper than an appeal.
Telehealth modifiers: 95, 93, and FQ for audio-only visits
Telehealth billing depends on three things lining up on the claim: the CPT/HCPCS code for the service actually performed, a modifier declaring how it was delivered, and a place-of-service code that agrees with the modifier. Internal medicine's telehealth volume runs heavily to follow-up visits and medication management, which makes this trio one of the highest-frequency modifier decisions in a telehealth-enabled IM practice.
| Modifier | Use | Concrete denial example |
|---|---|---|
95 | Synchronous audio-video telehealth — real-time video visit | Billed with an in-person place-of-service code instead of the telehealth POS — the modifier says video visit, the POS says office visit, and the internally inconsistent claim denies before medical necessity is even reviewed. |
93 | Synchronous audio-only telehealth — a real-time phone call, no video component, for a service on Medicare's audio-only-eligible list | Billed as 95 instead of 93 because the practice defaults to the "usual" telehealth modifier — if the visit was genuinely audio-only and gets billed as 95, a payer audit comparing the modifier against the visit record (or the patient's own statement) can trigger a post-payment recoupment. |
FQ | Identifies a service furnished using audio-only communication technology; commonly required alongside 93 on qualifying claims from federally qualified health centers and rural health clinics | An FQHC bills 93 alone on an audio-only visit without the required FQ — the claim denies for missing the site-type-specific modifier the payer's system expects on that claim type. ⚠️ We could not confirm FQ's exact applicability outside FQHC/RHC billing against a primary CMS source; verify with your specific MAC or payer before assuming it applies (or doesn't) to a standard office-based claim. |
The place-of-service code matters as much as the modifier itself. POS 10 (patient's home) and POS 02 (other non-home telehealth location) carry different reimbursement implications on Medicare claims, and the POS-and-modifier pairing has changed more than once as telehealth policy evolved after 2020 — confirm the current pairing your specific MAC or commercial payer expects before batch-submitting telehealth claims rather than assuming last year's rule still holds.
Not sure your internal medicine modifier logic is right?
We'll audit a sample of your recent claims for modifier 25 documentation gaps, EKG code-selection errors, and telehealth modifier/POS mismatches, and show what's recoverable.
Frequently asked questions
Can we bill modifier 25 every time an Annual Wellness Visit and a problem visit fall on the same day?
Yes, but only when the two services are genuinely separate in the note — the AWV's health risk assessment, cognitive screen, and prevention plan can't double as the E/M's history or MDM, and the reverse. The failure mode usually isn't the modifier being wrong technically; it's a payer system flagging the claim as duplicative because the same diagnosis code shows up on both lines with content that reads like one visit split into two claims. Run the strip test before submitting: remove the AWV content from the note and ask whether what's left is still a complete, billable E/M on its own. If it isn't, modifier 25 won't save the claim.
Is modifier 59 ever appropriate on an EKG code in internal medicine?
Rarely, and usually not the way practices assume. 93000 (global), 93005 (tracing only), and 93010 (interpretation only) are mutually exclusive for a single EKG on a single date — billing more than one of the three for the same tracing is a code-selection error, not an edit a modifier can bypass. Modifier 59 or an X-modifier applies only when a second, medically necessary tracing is genuinely performed the same day, such as a patient developing new chest pain mid-visit — and even then, a true repeat of the identical test by the same physician is usually modifier 76, not 59.
Do we need modifier FQ in addition to modifier 93 for an audio-only visit?
It depends on who's billing. Medicare's definition of modifier FQ is that the service was furnished using audio-only communication technology, and federally qualified health centers and rural health clinics are commonly required to append it alongside 93 on qualifying audio-only claims. We could not confirm the exact non-FQHC applicability of FQ against a primary CMS source during this build; confirm with your specific MAC or payer policy whether FQ is required outside the FQHC/RHC context before building it into a scrubber rule for a standard office-based claim.
Verify before billing. CPT is a registered trademark of the American Medical Association; codes here are paraphrased, not reproduced from the CPT Professional edition. CPT, HCPCS and ICD-10 codes, coverage policy, and bundling edits change, including annual code-set updates. This page reflects standard industry practice and is provided for general education — it is not a substitute for your own compliance review, your current payer contracts, or the current-year code sets. Confirm requirements against your specific payer mix before submitting claims.