Primary care medical billing services
E/M levels that decide the whole economics of the practice, preventive and problem visits colliding on one date of service, and care-management revenue almost nobody bills.
Also called: Family Practice · Family Medicine · General Practice. We keep one page per specialty rather than a page per name.
Why primary care billing is different
Primary care lives or dies on evaluation and management coding. There is no high-value procedure to carry the practice, so a systematic half-level of undercoding across every encounter is not a rounding error — it is the margin. Since the E/M guidelines moved to medical decision making or total time, the documentation that supports a level has changed, and a lot of practices are still coding to habits formed under the old rules.
The second issue is unique to this specialty: preventive and problem care happening in the same appointment. A patient arrives for an annual wellness visit and mentions their knee. Both services are billable, but only if the problem-oriented work is separately documented and the claim carries modifier 25. Without it the payer bundles them and the practice is paid for one visit having delivered two.
Third, there is a whole layer of non-visit revenue — chronic care management, transitional care after a discharge, remote monitoring, advance care planning — that is legitimately payable, requires specific consent and time documentation, and goes unbilled in the majority of independent practices.
Codes we work with
The families this specialty actually bills, and where each one carries a rule worth knowing.
| Family | Range | Notes |
|---|---|---|
| Office E/M | 99202–99215 | Level selected on medical decision making or total time |
| Preventive medicine visits | 99381–99397 | By age and by new or established patient |
| Medicare annual wellness | G0402, G0438, G0439 | Initial preventive exam, first AWV, subsequent AWV |
| Chronic care management | 99490, 99439, 99491, 99437 | Clinical staff time and physician time, per calendar month |
| Complex chronic care | 99487, 99489 | Higher time thresholds and moderate to high decision making |
| Transitional care management | 99495, 99496 | Post-discharge, with contact and visit timing requirements |
| Remote physiologic monitoring | 99453, 99454, 99457, 99458 | Setup, device supply and management time |
| Advance care planning | 99497, 99498 | Time-based, may be billed alongside an AWV |
| Immunisation administration | 90460–90474 | Administration billed separately from the vaccine product |
Modifiers that matter
And the specific way each one is most often misused in this specialty.
| Modifier | Use | Common error |
|---|---|---|
| 25 | Significant, separately identifiable E/M on the same day as another service | Omitted when a problem is addressed at a preventive visit, so both services bundle into one payment |
| 33 | Preventive service with cost-sharing waived | Left off a qualifying preventive service, so the patient is billed cost-share incorrectly |
| 59 / XU | Distinct procedural service | Used where modifier 25 is the correct answer |
| 95 | Synchronous telehealth | Applied with a place of service the payer does not accept |
| GC / GE | Service performed by a resident under teaching rules | Required by some payers and routinely omitted |
Top denial reasons
With the CARC code you will see on the remittance, and what we do to stop each one recurring.
| Denial | CARC | How we prevent it |
|---|---|---|
| Problem visit bundled into the preventive visit | CO-97 | Modifier 25 applied where the documentation genuinely supports separate work |
| Preventive service frequency exceeded | CO-119, CO-96 | Eligibility check returns the last covered date before the visit |
| Screening diagnosis does not support the service | CO-50 | Diagnosis-to-service mapping checked against payer preventive policy |
| Wellness visit billed for a patient not yet eligible | CO-B15 | Medicare AWV eligibility verified against enrolment dates |
| Care management billed without documented consent or time | CO-16 | Consent and monthly time captured in the template, not reconstructed later |
Prior authorisation in this specialty
Primary care carries a lighter direct authorisation burden than procedural specialties, but it absorbs the referral side of it. Advanced imaging ordered from the clinic, specialist referrals under HMO plans, and a growing list of drugs need authorisation before the patient can proceed. When that work sits with the front desk it competes with check-in. We take requirement determination, submission and follow-up off the desk, and flag referral requirements during eligibility verification so they surface before the appointment rather than after.
Where revenue leaks
- Chronic care management and transitional care management never billed at all
- Problem-oriented work at a wellness visit bundled away for want of modifier 25
- Systematic undercoding of established-patient visits under the current MDM rules
- Vaccine administration billed once when multiple components were given
What we do for primary care practices
The parts of the cycle where this specialty gains the most, framed for how it actually bills.
Medical Coding
Certified CPC and CCS coders assign and validate ICD-10, CPT, and HCPCS codes from your documentation.
See medical codingEligibility & Benefits Verification
Coverage and benefits confirmed before the visit, not after the denial.
See eligibility verificationMedical Billing & Coding Audits
Retrospective and pre-bill audits that find both compliance risk and missed revenue.
See billing & coding auditsPatient Billing & Collections
Statements, payment plans, and patient support that doesn't damage the relationship.
See patient billingSee what this specialty is losing in your practice
We run the analysis against primary care benchmarks, not a generic template. Send 90 days of claims data and keep the report either way.
Questions about primary care billing
Can you bill chronic care management for us?
Yes, including the consent record and the monthly time capture the codes require.
How do you handle a problem addressed at a wellness visit?
Both services are billed, with modifier 25 on the problem-oriented visit, where the documentation genuinely supports separate work.
Will you tell us if we are undercoding?
Yes. E/M distribution by provider is part of the monthly reporting, and a baseline audit is part of onboarding.
Do you bill vaccine administration separately?
Yes — the product and each administration component are billed as separate lines.
Adjacent specialties
Specialties whose billing shares rules, payers or authorisation patterns with this one.