2024 Family Medicine Billing Guidelines and Insights

Family medicine stands as the bedrock of primary healthcare, offering a holistic approach that encompasses care for individuals and families across all ages, genders, and a wide spectrum of health conditions. This medical specialty prides itself on its breadth, dealing with every organ system and disease entity. From heart disease, stroke, and hypertension to diabetes, cancer, and asthma, family medicine practitioners provide ongoing, personal care for the nation’s most serious health problems.

The critical role of family medicine practitioners in both rural and urban underserved areas cannot be overstated, as they provide the majority of healthcare services to these populations.

This guide will explore the extensive services offered by family medicine, highlighting the importance of preventive care, the complexities of evaluation and management, the value of minor office procedures, and all the medical coding that goes along with them.

Additionally, it underscores how healthcare organizations and hospitals can enhance both patient care and administrative efficiency through strategic partnerships with expert teams.

The Role of Family Medicine Practitioners

Family medicine is unique in its comprehensive approach to health care. Practitioners in this field are experts at treating a wide array of conditions, making them invaluable to the healthcare system.  

Family medicine practitioners include:

  • Medical Doctors (MD) 
  • Doctor of Osteopathic Medicine (DO) 
  • Clinical Nurse Practitioners (CNP) 
  • Physicians Assistants (PA)

Their role extends beyond mere treatment of illnesses; they are pivotal in preventive care, taking social determinants and community-level factors into account when offering routine checkups, health-risk assessments, immunizations, and personalized lifestyle counseling to foster long-term health.

❗ Did you know that at the age of 18, many adults often transfer to internal medicine practitioners from pediatricians who specialize in adult medicine only?  

❕ Did you know that children can stay on their parents’ family insurance until the age of 26?  

The Importance of Preventive Care in Family Medicine

Preventive care stands as a fundamental aspect of family medicine, dedicated to reducing the risk of diseases and health conditions before they arise. The role of family medicine practitioners in this preventative approach is pivotal, as they are at the forefront of administering vaccines, performing screening tests, and providing pre-surgical evaluations.

These services are crucial for the early detection of health conditions, which can significantly influence patient outcomes. By focusing on prevention, family medicine practitioners not only improve the quality of life for their patients but also contribute to the reduction of healthcare costs by minimizing the need for more extensive treatments.

Scope of Practice

There are several types of office encounters patients may experience when seeing a family medicine practitioner. These services range from new or established visits, preventative visits, wellness visits for adolescents, minor procedures, vaccines, and more. 

Larger-scale family medicine offices may offer radiology, laboratory, and physical therapy services for the convenience of their patients.

Let’s begin exploring many of our patient encounter types.

Evaluation and Management in Family Medicine

Evaluation and Management (E/M) codes categorize a wide array of services, including office visits, hospital care, and professional consultations, based on the complexity of medical decision-making or the duration of the patient encounter.

These E/M codes further differentiate between new and established patients, a distinction that plays a crucial role in the billing process. Mastery of these coding complexities is essential for accurate billing and ensuring proper reimbursement, underscoring the necessity for healthcare organizations to have efficient billing practices in place.

We can distinguish between new and established patients and professional services as those face-to-face services rendered by physicians and other qualified healthcare professionals who may report evaluation and management services.

A “new patient” is defined as someone who has not received any professional services from the physician or any other physician of the same specialty or subspecialty within the same group practice in the last three years.

On the other hand, an “established patient” has received professional services from the physician or a colleague in the same specialty within the same group, also within the last three years. This clear distinction is vital for healthcare providers to understand in order to navigate the complexities of E/M coding effectively.

In the instance where a physician or other qualified healthcare professional is on call for or covering for another physician or other qualified healthcare professional, the patient’s encounter will be classified as it would have been by the physician or other qualified healthcare professional who is not available. When advanced practice nurses and physician assistants are working with physicians, they are considered to be working in the exact same specialty and subspecialty as the physician.

Elements of Medical Decision Making
Level of MDM (Based on 2 out of 3 Elements of MDM) Number and Complexity of Problems Addressed at the Encounter Amount and/or Complexity of Data to Be Reviewed and Analyzed *Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below. Risk of Complications and/or Morbidity or Mortality of Patient Management
Straightforward 99202 EP, 99212 EP Patient returns to review lab results. Fatigue has resolved. no additional labs order Fatigue G93.32 patient to return in one year for annual exam. Labs were normal.
Low 99203 NP, 99213 EP Patient comes in with sore throat strep culture negative separately billable Pain in throat R07.0 return if pain continues
Moderate 99204 NP, 99214 EP Patient with two chronic condition : Hypertension I10 and Type 2 diabetes mellitus with diabetic nephropathy E11.21 Finger stick done in office separately billed Hydrochlorothiazide 25 mg for hypertension and Levemir FlexPen 100 U/ML return in 6 months.
High 99205 NP, 99215 EP Patient seen for chronic hypertension high blood pressure reading today and complaining of chest pain. Personally reviewed 3 labs and last chest x-ray done in urgent care 2 months ago when patient had pneumonia. X-ray showed pneumonia. EKG ordered and read in office separately billable Elevated blood pressure with hypertension I10, Chest pain R07.9 and abnormal EKG R94.31 Patient instructed to go directly to the hospital for admission.

Preventive Visits and Wellness Checks

Family medicine emphasizes regular wellness checks and preventive visits, tailored to each life stage. From birth through adulthood, these visits are designed to monitor and promote optimal health.

Infants and toddlers’ preventative visits are more frequent between birth and 4 years old, with a total recommended of 13 well-child or wellness visits. Frequent assessments are crucial for tracking growth and development, while adolescents and adults benefit from annual check-ups that focus on preventive measures and health maintenance. These visits include:

  • Measurement
  • Sensory screening
  • Mental and social behaviors
  • Behavioral and mental health
  • Physical examination
  • Procedures, if necessary
  • Anticipatory guidance
  • Immunizations

These visits provide an excellent opportunity for patients and practitioners to discuss health concerns and preventive strategies in depth.

Beginning at the age of 4, children will begin receiving yearly preventative visits throughout their adolescents, teenage years, and into adulthood. These visits should be billed with new or established preventative visit codes, which range from 99381–9387 for new patients to 99391–9397 for established patients.

Pediatric Wellness Visits

Preventive Medicine Services: Medicare Patients CPT Codes ICD-10-CM Codes
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings
G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit (second 12 months after enrollment) Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings
G0439 Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit Z00.00 General adult medical exam without abnormal findings orZ00.01 General adult medical exam with abnormal findings

When vaccines are administered during wellness visits, modifier 25 should be used on the E/M code to represent a separately identifiable visit. Vaccines should be billed with counseling codes if counseling is performed. If counseling was not performed, separate administrative CPT codes would be used. Our next set of CPT codes will represent the types of vaccines administered by listing each code multiple times or using the times (x) symbol to indicate the number given.

Modifier -51 should not be reported for vaccines or toxoids when performed with these administration codes (90460-90474).

90686 Influenza virus vaccine, quadrivalent, preservative free, 0.5 mL dosage
Preventive Medicine Services: Immunization Administration CPT Codes ICD-10-CM Codes
90460 Immunization administration (IA) through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered Z23 Encounter for Immunization
Add on 90461 each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure.) Z23 Encounter for Immunization
90471 IA (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) Z23 Encounter for Immunization
Add on 90472 each additional vaccine (single or combination vaccine/toxoid) (List separately to code for primary procedure.) Z23 Encounter for Immunization
90473 IA (includes intranasal or oral administration); one vaccine (single or combination vaccine/toxoid) Z23 Encounter for Immunization
Add on 90474 each additional vaccine (single or combination vaccine/ toxoid) (List separately to code for primary procedure.) Z23 Encounter for Immunization
Pediatric Vaccines ICD-10-CM Codes
90460 Pediatric IA (meningococcal and HPV), first component Z23 Encounter for Immunization
90461 Pediatric IA (DTaP vaccine), each additional component Z23 Encounter for Immunization
90471 IA, first injection Z23 Encounter for Immunization
90472 IA, each additional injection Z23 Encounter for Immunization
90474 IA, each additional oral or intranasal Z23 Encounter for Immunization
90633 Hepatitis A vaccine product Z23 Encounter for Immunization
90649 HPV, types 6, 11, 16, 18 quadrivalent (4vHPV), 3 dose schedule, for intramuscular Z23 Encounter for Immunization
90651 HPV (9-valent) product Z23 Encounter for Immunization
90672 Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use Z23 Encounter for Immunization
90696 Diphtheria, tetanus toxoids, and acellular pertussis vaccine and inactivated poliovirus vaccine (DTaP-IPV), when administered to children 4-6 years of age, for IM use Z23 Encounter for Immunization
90697 Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, w PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for IM use Z23 Encounter for Immunization
90700 DTaP product Z23 Encounter for Immunization
90702 Diphtheria and tetanus toxoids (DT), adsorbed when administered to younger than seven years, for IM use Z23 Encounter for Immunization
90715 Tdap product Z23 Encounter for Immunization
90744 Hepatitis B vaccine product Z23 Encounter for Immunization
Vaccine Adult Medicare Patient ICD-10-CM Codes
G0008 Administration of Influenza virus vaccine Z23 Encounter for Immunization
G0009 Administration of pneumococcal vaccine Z23 Encounter for Immunization
G0010 Administration of Hepatitis B vaccine Z23 Encounter for Immunization

Example of pediatric wellness visit  

A 4-month-old female established patient presents for her checkup. The mother states that the patient drinks 4 oz. bottles every 2-3 hours and wakes up once in the middle of the night. There are no concerns about any developmental delays. The physical exam shows normal height and weight within normal limits for her age. I will see her back for a 6-month wellness visit.

The following vaccines are ordered: Pentacel (diphtheria-tetanus-acellular pertussis [DTaP], Haemophilus influenzae type b [Hib], inactivated poliovirus [IPV]), pneumococcal, and rotavirus. The physician counsels the parents on all of them, consent is obtained, and the nurse administers them all.

Assessment and plan: 

  • 99391 modifier 25 Preventive medicine service, established patient, <1 year diagnosis code Z00.129 Routine child health exam without abnormal findings 
  • 90698 DTaP-Hib-IPV (Pentacel) product diagnosis code Z23 Encounter for Immunization 
  • 90670 Pneumococcal product Z23 Encounter for Immunization 
  • 90680 Rotavirus Vaccine, Oral Use Z23 Encounter for Immunization 
  • 90460 (×3) Pediatric IA (Pentacel, pneumococcal, rotavirus), first component diagnosis code Z23 Encounter for Immunization   90461 (×4) Pediatric IA (Pentacel), each additional component diagnosis code Z23 Encounter for Immunization 

Adult Wellness Visit

Example of an adult wellness visit

An 18-year-old female patient presents to the office for her annual checkup and to complete a college physical examination (in college, the patient will be living in a dormitory). The patient has no complaints and is excited to start her first year of college. I will be rooming with a friend from high school. Parents also have no major concerns currently. The patient is healthy with a normal physical exam and due for a Tdap booster, meningococcal vaccine, first HPV (9-valent) vaccine, and influenza vaccine. The physician counsels the patient and mother only on the meningococcal and HPV vaccines, and the nurse administers each. The patient is asked to return in 4 to 6 weeks (about 1 and a half months) for her second HPV vaccine before she leaves for school.

Assessment and plan:

  • 99395 modifier 25 Preventive medicine service, established patient, 18 years of age or older Z00.0 General adult medical exam without abnormal findings and Z02.0 Encounter for examination for admission to an educational institution
  • 90734 Meningococcal (MCV4) product Z23 Encounter for Immunization 
  • 90651 HPV (9-valent) product Z23 Encounter for Immunization 
  • 90460 (×2) Pediatric IA (meningococcal and HPV), first component Z23 Encounter for Immunization 
  • 90715 Tdap product Z23 Encounter for Immunization 
  • 90472 (×2) IA, each additional injection (Tdap) Z23 Encounter for Immunization  90686 Influenza virus vaccine, quadrivalent, preservative-free, 0.5 mL dosage Z23 Encounter for Immunization

When a patient is present in the office for a preventative visit and they are sick, a sick visit can be billed with modifier 25 listed on the wellness visit. The E/M code is selected on MDM, or time. If time is a factor when selecting a code level for the sick visit, remember that any time spent on the patient’s wellness visit is not counted. 

Medicare Wellness

Medicare wellness visits represent an essential part of care for patients aged 65 and above as part of the Medicare or Medicare Advantage Plans. These visits, which are different from routine physician exams, are aimed at creating personalized prevention plans.

Medicare and the Medicare Advantage Plan require the use of HCPCS codes, which are based on patients’ Medicare enrollment dates, the first 12 months from the date of enrollment, the following 12 months, and subsequent visits thereafter.

If a patient does not complete their Welcome to Medicare Visit G0402 within the first 12 months following enrollment, the visit should be billed with the G0438 Annual Wellness Visit.  

Preventive Medicine Services: Medicare Patients CPT Codes ICD-10-CM Codes
G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings
G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit (second 12 months after enrollment) Z00.00 General adult medical exam without abnormal findings or Z00.01 General adult medical exam with abnormal findings
G0439 Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit Z00.00 General adult medical exam without abnormal findings orZ00.01 General adult medical exam with abnormal findings

The goal of an Annual Wellness Visit is to create an individualized plan to maintain your health. Items addressed during this visit include:

  • Vital signs, height and weight
  • Health history update, including allergies
  • Hearing screening
  • Advanced Care Planning
  • Review of your current medications, vitamins and supplements
  • Depression screening
  • Cognition screening
  • Mobility screening
  • Vaccination review

When conducting a sick visit or discussing chronic conditions, you can include an Evaluation and Management (E/M) code alongside G0402, G0438, and G0439. However, it’s important not to apply E/M codes for appointments solely involving medication refills.

Additionally, when determining the level of E/M service, remember that certain tests and screenings—like lab work, EKGs, bone density assessments, mammograms, and colonoscopies—do not factor into the medical decision-making (MDM) process, as they fall under the umbrella of Medicare Wellness Codes.

Certain Medicare Advantage Plans may permit the concurrent billing of wellness visits and Medicare Wellness Visits. For instance, National Government Services Medicare (NGS) specifically recognizes G0402, G0438, and G0439 for such instances.

Minor Office Procedures in Family Medicine

Within the scope of family medicine services, practitioners are adept at performing a variety of minor office procedures, ensuring both safety and efficiency with minimal complications. These procedures typically involve the use of local anesthetics, either injected or applied topically, to ensure patient comfort.

Common office procedures include earwax (cerumen) removal, suture removal, wart excision, joint injections, and the treatment of ganglion cysts, to name a few. Earwax removal, for instance, addresses the issue of accumulated earwax that can obstruct hearing, a problem often resolved with simple treatments that may include over-the-counter ear drops.

In cases where stitches applied in an emergency setting need removal or when patients require cortisone injections for joint pain, these services are expertly provided within the family medicine practice, often saving a visit to a specialist. Other minor procedures conducted include the removal of foreign objects, treatment of ingrown toenails, and abscess drainage, ensuring comprehensive care is maintained within a familiar setting.

For conditions like osteoarthritis, we utilize specific treatments such as arthrocentesis (code 20610) to provide relief and improve joint function. It’s important to note that when a patient undergoes an Evaluation and Management (E/M) visit and receives a minor procedure, we apply modifier 25 to the E/M code to accurately reflect the services provided.

Our commitment to regular, consistent care fosters strong, communicative, and trustworthy relationships with our patients, establishing a foundation of trust and understanding that is pivotal in family medicine. This approach ensures that patients receive comprehensive care tailored to their individual needs, all within the comfort of our practice.

Next Steps

Navigating the complexities of medical coding and billing in family medicine, with its diverse range of services and codes applicable to various age groups, can be a challenging task for any healthcare organization and medical practice.

If you’re facing challenges in this aspect of your healthcare organization, we invite you to connect with us at Neolytix. Our team is specialized in providing support in medical billing, coding, and revenue cycle management, ensuring your practice operates smoothly and efficiently.

Our services are not only 100% HIPAA-compliant but also delivered by a team of certified professionals well-versed in the latest industry standards and practices. We also offer medical credentialing services that are both swift and systematically organized, following stringent workflow management protocols to ensure the utmost efficiency.

For practices looking to enhance their coding accuracy, reduce billing errors, and optimize revenue, Neolytix stands ready to assist. Reach out to us for a no-obligation consultation and discover how our billing services can transform your practice’s operational dynamics.

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