Family & internal medicine billing, handled with care
Where family & internal medicine billing gets difficult
The issues we see most often, and the ones that quietly cost practices the most.
E/M level selection
Office visit levels are based on medical decision-making or total time, and inconsistent documentation can lead to under- or over-coding.
Preventive and problem visits together
When a problem is addressed during a preventive visit, both may be billable, but patients may be surprised by cost sharing.
Care management requirements
Chronic care management and similar programs require consent, care plans and tracked time each month.
Medicare wellness services
Annual wellness visits differ from physical exams, and patients often confuse the two.
How we handle them
E/M documentation review
We review visit documentation for decision-making or time and offer providers clear, practical feedback.
Preventive visit coding
We code preventive services and screenings based on the patient’s age and plan, with problem-oriented visits reported separately when appropriate.
Care program billing
We help set up workflows for chronic care management and related programs so eligible time is captured each month.
Wellness visit support
We help your team schedule and bill Medicare wellness visits correctly and explain them clearly to patients.
Coding notes
General guidance only. Code sets update every year and payer policies vary, so we check current rules on every claim.
- Office E/M by MDM or time
- Since 2021, office visit levels (99202–99215) are chosen based on medical decision-making or total provider time on the date of the encounter. History and exam should be documented as medically appropriate but do not determine the level.
- Preventive versus problem-oriented
- Preventive visits use age-based codes (99381–99397). If a significant problem is addressed, a problem-oriented E/M with modifier 25 may also be billed, and patient cost sharing may apply.
- Chronic care management
- CCM codes such as 99490 and 99439 apply to patients with two or more chronic conditions. They require patient consent, a care plan and tracked care management time each calendar month.
- Medicare annual wellness visit
- G0438 is the initial annual wellness visit and G0439 is each subsequent visit. These focus on prevention planning and are different from a routine physical exam, which Medicare generally does not cover.
Family & internal medicine billing questions
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