Family medicine billing
Newborns to Medicare patients, each checkup coded to its payer’s rules.
A family practice bills a toddler on Medicaid, an adult on an employer plan and a retiree on Medicare in one morning, under different rules. We code each checkup by age and payer, add the problem visit when it is earned, and match vaccine codes to the plan.
- Full-service rate
- 3% to 6% of collections
- Same-day visits
- Preventive + problem, mod 25
- Payer mix
- Medicare, Medicaid, commercial
- New & smaller practices
- Flexible monthly minimum
What makes family medicine billing different
Family medicine is the specialty where the same checkup is coded several ways depending on who walks in. A 4-year-old on Medicaid, a 35-year-old on an employer plan and a 70-year-old on Medicare each need a different code, a different payer rule and a different answer about what the patient owes.
Then a problem comes up mid-visit, the vaccines go in, and a depression follow-up starts. We code all of it from the note, as part of our full revenue cycle service at 3% to 6% of collections.
The checkup, by age and by payer
What each payer pays for a preventive visit. Plans set their own frequency limits, so we check each patient’s benefits first.
- Children on MedicaidWell-child visits under EPSDT, on the state’s schedule, for members under 21.
- Commercial plansPreventive codes 99381 to 99387 (new) or 99391 to 99397 (established), by age group. Recommended care in network has no cost sharing.
- New to MedicareThe Welcome to Medicare visit (IPPE, G0402), covered only in the first 12 months of Part B.
- Original MedicareThe annual wellness visit (G0438, G0439) once every 12 months. A routine physical is not covered.
- Medicare AdvantageSome plans also pay the preventive codes, but not on the same date as a Medicare wellness visit.
- A problem addressedAn office visit (99202 to 99215) with modifier 25, on top of any of the above, when the work is significant.
A problem visit on the same day as the checkup
When a new or existing problem takes real work during a preventive visit, you bill both: the preventive code and an office visit with modifier 25. A rash you note but do not treat is not enough. AAFP’s guide to combined visits sets the test as some medical decision making; its example is a 49-year-old’s checkup (99396) where fatigue and insomnia are worked up and labs ordered (99213 with modifier 25).
Who pays differs. Under 45 CFR 147.130, health plans cover recommended preventive services in network with no copay or deductible, but may apply cost sharing to a separately billed office visit. Original Medicare does not cover routine physicals. Under chapter 12 of the Medicare Claims Processing Manual, a covered visit given with a noncovered physical is paid, the patient can be charged the difference between your two fees, and CMS strongly encourages an ABN first.
Our eligibility and benefits checks tell your front desk what each patient is likely to owe before the visit, so the bill is not a surprise.
Vaccine administration codes by payer
Medicare Part B covers four preventive vaccines, each with its own administration code: flu (G0008), pneumococcal (G0009), hepatitis B for patients at intermediate or high risk (G0010) and COVID-19 (90480), with no deductible or coinsurance. Other preventive vaccines fall under Part D, so the AAFP’s Medicare vaccine guide has the office charge the patient and hand over a claim form to file with their drug plan.
For other payers, children counseled by the physician get 90460 and 90461 (our pediatric billing page shows how to count them), and everyone else gets 90471 to 90474. The 2026 NCCI policy manual bars mixing the two ranges on one date and bars 99211 with any vaccine administration, and a patient who comes back only for a shot gets the administration code alone.
Modifier 25 differs too. Per the AAFP’s modifier 25 guide, Original Medicare does not need it on an office visit billed with G0008, G0009 or G0010, but does with 90480 and the CPT administration codes.
Behavioral health integration in a family practice
Medicare pays monthly for managing depression, anxiety and other behavioral health conditions inside primary care. Per CMS’s behavioral health integration booklet, general BHI (99484) needs at least 20 minutes of clinical staff time in a calendar month. The collaborative care model adds a care manager and a psychiatric consultant: 99492 for 70 minutes in the first month, 99493 for 60 minutes in later months, 99494 for each further 30, and G2214 for 30 minutes.
Both need an initiating visit (an AWV, IPPE, TCM or comprehensive E/M) and consent, which can be verbal, after telling the patient cost sharing applies. General BHI and collaborative care cannot be billed for one patient in the same month. From 2026, practices billing advanced primary care management can report this work with optional add-ons: G0568 and G0569 for collaborative care, G0570 for general BHI.
Why family medicine claims deny
Common reasons, with the reason codes that often carry them (codes vary by payer):
- A routine physical (99381 to 99397) sent to Original Medicare (PR-49 or CO-49)
- A preventive code that does not match the patient’s age (CO-6)
- A checkup sooner than the plan’s frequency limit (CO-119)
- A problem visit with no modifier 25 next to the checkup or a vaccine (CO-97)
- Codes from both vaccine administration ranges, or 99211 with a shot (CO-236 or CO-97)
- A Part D vaccine billed to Medicare Part B (CO-109)
Each one goes through our denial management process, corrected and resubmitted or appealed inside the payer’s deadline.
How we run family medicine billing
Verify benefits by age and plan
Before each checkup we confirm the payer, the last preventive or wellness visit date, and what a problem visit will cost the patient.
Code the visit from the note
The preventive code by age, the problem visit with modifier 25 when the note supports it, and vaccine codes matched to the payer.
Track the monthly codes
BHI and care management minutes, consents and initiating visits are tracked per patient, so each month’s claim is supported.
Work every denial
Denials are sorted by payer and reason code, then corrected or appealed with the note.
Report monthly
Collections, days in A/R, denials by reason and preventive visit volume, by payer and by provider.
Credentialing for family physicians
A family practice bills every payer type, so each physician, NP and PA needs Medicare, the state Medicaid program and each of its managed care plans, plus the Medicare Advantage and commercial plans you accept. Plan on 90 to 120 days for a full set of payers. Our provider credentialing service handles all of them at $189 per payer application, $150 per payer for up to 7 payers and $120 per payer for up to 20, with no setup fees.
What changes for these providers, step by step: see nurse practitioner credentialing.
Family medicine billing questions
Something else? Call +1 786-788-7313. A biller answers.
All questionsUsually because a problem was treated at the same visit. Health plans must cover recommended preventive care in network with no cost sharing, but the separate office visit for the problem, billed with modifier 25, can carry a copay or deductible. So can treatment that follows a screening, and care from an out-of-network provider.
No. Original Medicare does not cover the preventive codes 99381 to 99397. It pays for the Welcome to Medicare visit (G0402) in the first 12 months of Part B and the annual wellness visit once every 12 months. If a Medicare patient wants a full physical, they pay for the noncovered part, and CMS strongly encourages an ABN beforehand.
G0008 for flu, G0009 for pneumococcal and G0010 for hepatitis B, plus 90480 for COVID-19. Those four vaccines are covered under Part B with no deductible or coinsurance. Other preventive vaccines, such as RSV, are covered through the patient’s Part D plan, so you bill the patient and give them a claim form to send to their drug plan.
Monthly codes for managing a behavioral health condition in primary care: general BHI (99484), at least 20 minutes of staff time a month, or the collaborative care model (99492 to 99494, G2214) with a care manager and a psychiatric consultant. Both need an initiating visit and documented consent, and not both for one patient in the same month.
No. Under the NCCI policy manual, all vaccine administrations on one date, other than the Medicare G-codes for flu, pneumococcal and hepatitis B, come from one range or the other: 90460 and 90461 for counseled children, or 90471 to 90474, never both. A significant, separate office visit the same day can still be billed with modifier 25.
Our full-service rate is 3% to 6% of monthly collections, set by your volume, with no setup or onboarding fees and flexible monthly-minimum plans for new and smaller practices. It covers eligibility checks, prior authorizations, coding, claims, payment posting, denials and A/R follow-up, plus preventive and vaccine code checks. Your exact rate comes after a free A/R review. Our guide to medical billing costs shows how to compare quotes.
Yes. We don’t list our clients on this site, but ask us and we’ll arrange it: with a current client’s permission, we share their contact details so you can hear how we work from them directly.
From our guides
How to calculate days in A/R
The formula with a worked example and a calculator, the benchmarks, why a good average can hide old claims, and the fixes that bring days in A/R down.
How much do medical billing services cost?
The four ways billing companies price their work, the fees that sit outside the rate, and in-house arithmetic built from BLS data, so you can compare quotes on your own numbers.
Send us your last 90 days of family medicine claims.
We’ll review them free and show you where preventive codes, modifier 25 or vaccine codes are costing you money.