G4025 Physical Medicine MIPS — Reimbursement & Policy | OpenPayer

Summary & Overview

HCPCS G4025: Physical Medicine MIPS Specialty Set

HCPCS Level II code G4025 identifies the physical medicine MIPS specialty set, a defined group of measures used for performance reporting under the Merit-based Incentive Payment System. Nationally, MIPS reporting affects provider payment adjustments and public quality reporting, making accurate identification and reporting of specialty measure sets important for clinicians in physical medicine. This code is relevant to outpatient physical medicine practitioners, including those in physical therapy clinics and physician offices that participate in MIPS.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of what the code represents, its clinical and reporting context, and which payers commonly interact with this billing designation. The publication outlines benchmarking concepts, typical sites of service for reporting, and the role of G4025 in national performance measurement frameworks.

What readers will learn: the purpose of HCPCS Level II code G4025, its relevance to national MIPS reporting for physical medicine, expected clinical settings where the specialty set applies, and which major payers are engaged with MIPS-related reporting. Data not available in the input will be noted where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareG4025HCPCS Level IIPhysical MedicineMIPSQuality ReportingPerformance MeasuresOutpatientPhysical TherapyClinical Reporting

Billing Code Overview

HCPCS Level II code G4025 denotes the Physical medicine MIPS specialty set. This code represents a group or bundle of quality/performance measures or services tied to the physical medicine specialty for reporting under the Merit-based Incentive Payment System (MIPS).

Service type: Performance measurement and reporting set for physical medicine
Typical site of service: Performance and reporting activities apply across outpatient physical medicine settings, including physical therapy clinics and physician offices; applicable where MIPS reporting occurs

Data not available in the input.

Clinical & Coding Specifications

Clinical Context

A typical patient is a 55-year-old individual referred to a physical medicine clinic for ongoing management of musculoskeletal pain and functional impairment following a lumbar strain and deconditioning after surgery. The clinician uses the G4025 Physical medicine MIPS specialty set as part of a Merit-based Incentive Payment System (MIPS) reporting workflow to capture quality, improvement activity, and cost measures for the physical medicine specialty. The patient visit includes a focused history, standardized outcome measure administration (for example, pain numeric rating scale and functional status instrument), objective physical examination, development or revision of a rehabilitation plan (therapeutic exercises, manual therapy, home exercise program), and documentation of patient education and shared decision-making.

The clinical workflow: the patient checks in for an outpatient clinic visit in a hospital outpatient department or freestanding rehabilitation clinic. The clinician documents baseline measures, completes the elements required by the MIPS specialty set G4025 (including specified quality and improvement activities), codes the visit with the appropriate evaluation and management or therapy CPT codes, appends relevant modifiers based on service circumstances (for example 22 for increased procedural services or 52 for reduced services), and includes G4025 for reporting the specialty MIPS set to payors or registries as required. Typical site of service is outpatient clinic or outpatient rehabilitation facility.

Coding Specifications

Modifier

HCPCS G0908: Hemoglobin Most Recent > 12.0 g/dl

HCPCS-G0455-FECAL-MICROBIOTA-INSTILLATION-PREPARATION

HCPCS G0455: Preparation and Instillation of Fecal Microbiota

HCPCS-G8843-NON-MEASUREMENT-AHI-RDI-REI-DOCUMENTATION

HCPCS G8843: Documentation for Not Measuring AHI/RDI/REI

HCPCS-G2058-CHRONIC-CARE-MANAGEMENT-ADDITIONAL-20-MIN

HCPCS G2058: Chronic Care Management, Additional 20 Minutes

HCPCS-G0058-LOWER-EXTREMITY-JOINT-REPAIR-CARE-IMPROVEMENT

HCPCS G0058: Improving Care for Lower Extremity Joint Repair, MIPS VA Pathway

HCPCS-G9860-HOSPICE-STAY-LESS-THAN-THREE-DAYS

HCPCS G9860: Patient Spent Less Than Three Days in Hospice Care

HCPCS-G0175-INTERDISCIPLINARY-TEAM-CONFERENCE-PATIENT-PRESENT

HCPCS G0175: Scheduled Interdisciplinary Team Conference with Patient Present

HCPCS-G0417-PROSTATE-NEEDLE-BIOPSY-PATHOLOGY-21-40-SPECIMENS

HCPCS G0417: Prostate Needle Biopsy Pathology, 21-40 Specimens

HCPCS-G4027-PLASTIC-SURGERY-MIPS-SPECIALTY-SET

HCPCS G4027: Plastic Surgery MIPS Specialty Set

HCPCS-G0477-PRESUMPTIVE-DRUG-TEST-OPTICAL-READ

HCPCS G0477: Presumptive Drug Test Read by Direct Optical Observation

Showing 1–10 of 1996

Taxonomy Code	Specialty	Notes
`2084P0800X`	Physical Medicine & Rehabilitation Physician	Commonly directs rehabilitation plans and MIPS reporting for physical medicine.
`225100000X`	Physical Therapist	Delivers therapeutic exercises, manual therapy, and functional outcome measures.
`363A00000X`	Physician Assistant	Provides evaluation and management and therapy services under supervision in outpatient rehab.
`367500000X`	Occupational Therapist	Provides activity-specific rehabilitation and functional training when indicated.
`208D00000X`	Pain Medicine Physician	Manages complex pain etiologies and coordinates interventional/rehab care.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M54.5`	Low back pain	Common reason for referral to physical medicine and rehabilitation and included in outpatient therapy plans captured in the MIPS specialty set.
`M48.06`	Spinal stenosis, lumbar region	Often managed with conservative physical medicine approaches and functional outcome measurement in MIPS reporting.
`M51.26`	Other intervertebral disc displacement, lumbar region	Indicates radicular symptoms and functional limitations addressed by therapeutic interventions in this specialty set.
`S39.012A`	Strain of muscle, fascia and tendon of lower back, initial encounter	Acute or subacute strain leading to physical medicine evaluation and therapy interventions documented for quality measures.
`M25.561`	Pain in right knee	Joint pain commonly managed with therapeutic exercise and functional training documented within the specialty set.
`M25.562`	Pain in left knee	As above, side-specific knee pain addressed with targeted rehabilitation and outcome tracking.
`G89.29`	Other chronic pain	Chronic pain syndromes frequently managed in physical medicine with multimodal rehabilitation documented in MIPS reporting.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`97110`	Therapeutic exercises to develop strength, range of motion and flexibility (per 15 minutes)	Commonly performed during outpatient rehabilitation visits alongside MIPS specialty set reporting.
`97112`	Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception (per 15 minutes)	Used when reeducation interventions are part of the physical medicine plan documented in the MIPS set.
`97140`	Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage) (per 15 minutes)	Performed by physical therapists or physicians and documented in the treatment plan tied to the MIPS specialty measures.
`97530`	Therapeutic activities, direct (one-on-one) patient contact (per 15 minutes)	Utilized for functional task practice and ADL training within the rehabilitation episode reported under `G4025`.
`99354`	Prolonged physician service in the office or outpatient setting requiring direct patient contact beyond the usual service; first hour (list separately in addition to office/outpatient E/M)	Applied when evaluation and management time exceeds typical visit duration and `22` modifier considerations are documented; may accompany MIPS reporting for time-intensive encounters.

`22`	Increased procedural services	When work, time, and complexity exceed usual services documented in the medical record.
`23`	Unusual anesthesia	When general anesthesia is medically necessary for a procedure that normally does not require it.
`52`	Reduced services	When a service is partially reduced or not completed as documented.
`53`	Discontinued procedure	When a procedure is started but terminated due to extenuating circumstances.
`54`	Surgical care only	When the billing provider performs only the surgical portion and not pre- or post-operative care.
`55`	Post-operative management only	When the billing provider performs only post-operative care.
`56`	Pre-operative management only	When the billing provider performs only pre-operative care.
`62`	Two surgeons	When two surgeons work together as primary surgeons performing distinct portions of a complex procedure.
`AS`	Physician assistant, nurse practitioner, or clinical nurse specialist service as primary provider	When a listed advanced practice provider performs the service as the primary clinician.

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