CMS Physician Fee Schedule
The published Medicare rates and payment rules behind most of the codes on this page.
Geriatrics billing hinges on stacking Annual Wellness Visits (AWV), Chronic Care Management (CCM), Behavioral Health Integration (BHI), cognitive impairment assessment, and advance care planning on the same patient — with modifier 25 protecting same-day problem E/M and HCC risk-adjustment capture driving every elderly panel’s revenue. General billers miss the stacking. MedFactor delivers geriatrics-specific RCM that captures every layered service.
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Chronic-Care Stacking — RCM PanelLive
Annual Care Stack — Per Elderly Beneficiary
AWV (first)G0438
AWV (subseq)G0444
CCM base99490
CCM add-on99439
BHI99484
Cognitive99483
ACP99497
0%Clean Claim Rate
0%Denial Reduction
0dDays in A/R
From general geriatric primary care to cognitive/memory clinics and home-based elder care, we tailor billing to the coding rules of every geriatrics subspecialty.
Primary Care
Annual wellness visits (G0438/G0444), preventive visits (99381-99397), and problem E/M (99202-99215) with modifier 25 stacking and HCC risk-adjustment capture.
Chronic Care
CCM 99490 base with 99439 add-on for additional 20 minutes, BHI 99484, and care-plan oversight for multi-condition elderly panels.
Cognition
Cognitive impairment assessment 99483, dementia ICD-10 (F01/F03, G30), and advance care planning 99497 with proper time documentation.
Transitions
TCM 99495/99496 within 7-14 days of discharge, polypharmacy Z79 coding, and medication reconciliation capture for high-risk elders.
Advance Care
99497 initial and 99498 subsequent advance care planning, goals-of-care discussions, and POLST/MOLST documentation linkage.
Home Care
Home visit codes (99341-99350), home-based CCM, and care-plan oversight for housebound and mobility-limited elderly patients.
Geriatrics revenue is built on stacking time-based care-management services on the same elderly patient across the year — AWV, CCM, BHI, cognitive assessment, and advance care planning — with a separately reportable problem E/M guarded by modifier 25 when done same-day as the AWV. This is the largest source of geriatric revenue leakage.
One elderly beneficiary can generate AWV, CCM with add-on minutes, BHI behavioral integration, a cognitive impairment assessment, and advance care planning — each separately billable when documented.
Wellness BaseAnnual Wellness Visit — first visit / subsequentG0438 / G0444
Chronic Care Management — base20 min+ care management per month99490
CCM add-on — additional 20 minEach additional 20 min of care management99439
Behavioral Health IntegrationBHI behavioral care management99484 / 99492-99494
Cognitive impairment assessment60-min cognitive assessment & care planning99483
Advance care planningFirst 30 min goals-of-care discussion99497
Problem E/M same-day as AWV (separately reportable, mod 25)Separate problem-focused visit — modifier 25 required99202-99215 · 25
Our focus: We document and stack each time-based service independently — AWV (G0438 first / G0444 subsequent) as the wellness base, CCM 99490 base with 99439 add-ons for each additional 20 minutes, BHI 99484 / 99492-99494 for behavioral integration, the 60-minute cognitive impairment assessment 99483, and advance care planning 99497 — while appending modifier 25 to any same-day problem E/M so it is paid separately from the AWV rather than bundled and denied.
Geriatrics billing is governed by time-based care-management stacking, cognitive assessment capture, and HCC risk-adjustment documentation that general billing companies cannot navigate effectively.
Annual wellness visits (G0438/G0444) denied when the required elements — risk assessment, care plan, cognitive screening — are not documented per the CMS template.
Severity
Chronic Care Management (99490) and the 99439 add-on denied when care-plan documentation or the 20-minute time threshold is not met and logged.
Severity
Behavioral Health Integration (99484, 99492-99494) under-captured when behavioral care management time and the psych clinical pathway are not documented.
Severity
The 60-minute cognitive impairment assessment (99483) is rarely billed because clinicians document cognition without meeting the full code requirements.
Severity
Transitional Care Management (99495/99496) missed when the 7-14 day post-discharge face-to-face visit window is not tracked and medication reconciliation is undocumented.
Severity
Hierarchical Condition Category (HCC) capture in elderly panels falls behind when chronic diagnoses (I10, E78, N18, E11) are not documented at every encounter, lowering RAF scores.
Severity
Quick reference for the most frequently used codes in geriatrics billing and coding.
CPT / HCPCS
ICD-10 Codes
Modifiers
| Code | Description | Common Use |
|---|---|---|
| G0438 | Annual Wellness Visit, initial | First AWV — risk assessment + care plan |
| G0444 | Annual Wellness Visit, subsequent | Yearly AWV thereafter |
| 99490 | Chronic Care Management, 20 min/month | CCM base for two+ chronic conditions |
| 99439 | CCM add-on, additional 20 min | Each additional 20 min of care management |
| 99437 | CCM, complex / extended (30 min) | Complex CCM extended time |
| 99484 | Behavioral Health Integration, base | BHI behavioral care management |
| 99492 | BHI, first 70 min in 1st month | BHI initial month |
| 99493 | BHI, first 60 min in months 2-6 | BHI ongoing months |
| 99494 | BHI, additional 30 min | BHI add-on time |
| 99483 | Cognitive impairment assessment, 60 min | Cognitive eval + care plan |
| 99495 | Transitional Care Management, moderate | 14-day F2F, low/med complexity |
| 99496 | Transitional Care Management, high | 7-day F2F, high complexity |
| 99497 | Advance care planning, first 30 min | Goals-of-care discussion |
| 99202-99215 | Office / outpatient E/M | New & established problem visits |
| 99381-99397 | Preventive medicine visits | Age-based periodic preventive exams |
| Code | Description | Clinical Context |
|---|---|---|
| I10 | Essential (primary) hypertension | Chronic condition / HCC capture |
| E78.x | Disorders of lipoprotein metabolism | Hyperlipidemia / HCC |
| N18.x | Chronic kidney disease | CKD staging / HCC |
| E11.x | Type 2 diabetes mellitus | Diabetes with complications / HCC |
| E10.x | Type 1 diabetes mellitus | Insulin-dependent diabetes |
| F01.x | Vascular dementia | Cognitive disorder / 99483 |
| F03.x | Unspecified dementia | Cognitive impairment coding |
| G30.x | Alzheimer’s disease | Alzheimer’s dementia |
| F32.x | Major depressive disorder | BHI / behavioral health |
| R54 | Age-related cognitive decline | Cognitive screening / 99483 support |
| Z79.x | Long-term (current) drug therapy | Polypharmacy / medication tracking |
| Z00.x | Encounter for general exam / screening | Annual wellness / preventive |
| Modifier | Description | Geriatrics Application |
|---|---|---|
| 25 | Separate E/M same day | Problem E/M with same-day AWV / procedure |
| 24 | Unrelated E/M in post-op global | Unrelated visit during surgical global period |
| 33 | Preventive service | Preventive visits / screenings |
| GC | Service by resident under MD supervision | Geriatrics teaching clinic services |
| 95 | Telehealth service | Remote CCM / BHI / behavioral health visits |
| 52 | Reduced service | Partial-time cognitive / care-management service |
| GA | Waiver of liability statement | AWV / advance care planning likely-to-be-denied |
| GT | Telehealth (legacy) | Telehealth delivery of CCM / BHI |
Comprehensive revenue cycle management designed specifically for geriatrics practices.
Specialty coders handle AWV elements, CCM time-stacking, BHI behavioral integration, 99483 cognitive capture, and HCC risk-adjustment with accuracy.
AWV element defense, CCM time documentation corrections, 99483 cognitive-requirement appeals, and 99497 advance-care-planning appeals.
Pre-authorization for cognitive testing, home health, DME, and behavioral health services tied to BHI and CCM care plans.
Prioritized follow-up on aged CCM, BHI, AWV, and TCM claims with strategic payer escalation to maximize recovery.
Regular audits focused on CCM time tracking, AWV element completeness, HCC capture, modifier 25 stacking, and 99497 documentation.
Real-time dashboards tracking CCM enrollment, BHI capture, AWV completion, HCC RAF scores, and physician productivity.
Understanding the most common denial reasons is the first step to preventing them on AWV, CCM, BHI, and cognitive-care claims.
Annual wellness visits (G0438/G0444) denied when the required CMS elements — risk assessment, care plan, cognitive screening — are not documented.
Element-by-element AWV documentation mapped to the CMS template, verified before claim submission.
Chronic Care Management (99490 / 99439) denied when the 20-minute monthly threshold or care-plan documentation is not logged.
Time-log validation and care-plan completeness checks before billing each CCM month.
The 60-minute cognitive impairment assessment denied when full requirements (assessment + care plan + caregiver input) are not documented.
99483 documentation templates capturing assessment, care plan, and caregiver input per code requirements.
Transitional Care Management (99495/99496) denied when the post-discharge face-to-face visit falls outside the 7-14 day window or medication reconciliation is missing.
Discharge-feed tracking with visit-window alerts and medication reconciliation documentation capture.
Identifying and plugging these common revenue leakage points can significantly improve your practice’s bottom line.
Additional 20-minute CCM increments not billed when time logs exceed 20 minutes.
Cognitive impairment assessment not billed when dementia care is delivered without full code documentation.
Chronic conditions documented historically but not re-captured at annual encounters, lowering RAF scores.
Transitional care management not billed when the post-discharge F2F visit timing slips outside the window.
See how geriatrics-specific revenue cycle management transforms your practice’s financial performance.
A structured onboarding process designed to deliver measurable improvements within the first 90 days.
1WEEK 1-2
Review of geriatrics billing operations, CCM/BHI stacking, AWV element capture, and HCC baseline.
2WEEK 3-4
EMR and care-management integration, dedicated geriatrics billing team, and payer enrollment verification.
3WEEK 5-8
Full billing with real-time claim submission, modifier 25 verification, and denial prevention protocols.
4WEEK 9-12
Performance review against baseline, workflow optimization, and documented revenue improvement.
How our geriatrics-specific approach compares to in-house billing and general medical billing companies.
| Capability | In-House Team | General Billing Co. | MedFactor Geriatrics |
|---|---|---|---|
| AWV (G0438/G0444) element capture | Inconsistent | ✕ | ✓ |
| CCM 99490 + 99439 add-on stacking | ✕ | ✕ | ✓ |
| BHI 99484 / 99492-99494 capture | ✕ | Partial | ✓ |
| Cognitive assessment 99483 documentation | Inconsistent | ✕ | ✓ |
| Modifier 25 same-day problem E/M with AWV | Inconsistent | Partial | ✓ |
| TCM 99495/99496 visit-window tracking | Manual | Partial | ✓ |
| Advance care planning 99497 capture | ✕ | Partial | ✓ |
| HCC / RAF risk-adjustment re-capture | ✕ | ✕ | ✓ |
| Dedicated geriatrics billing team | ✕ | ✕ | ✓ |
Our team combines deep geriatrics billing expertise with the technology and processes to deliver consistent, measurable results for elder-care practices.
Discover exactly where your geriatrics practice is losing revenue. Our no-obligation audit analyzes your CCM/BHI stacking, AWV element capture, and HCC risk-adjustment.
Schedule Your Free Audit
21%Average Revenue ImprovementGeriatrics practices see an average 21% improvement in net collections within the first year.
2 WeeksAudit Completion TimeComplete billing and coding audit delivered within 10 business days.
Real results from geriatrics practices that partnered with MedFactor for specialty revenue cycle management.
$310KRevenue Recovered
Geriatric Primary Care
A geriatric primary care practice was billing CCM 99490 only and dropping the 99439 add-ons for additional 20-minute increments. MedFactor implemented time-log validation and add-on stacking, recovering substantial care-management revenue in seven months.
42%Denial Reduction17dA/R Reduced
$265KAnnual Capture
CCM / BHI Chronic Care
A CCM-heavy chronic-care practice was delivering behavioral integration but never billing BHI 99484 / 99492-99494. MedFactor implemented BHI documentation alongside CCM, recovering behavioral-care revenue per patient per month.
$265KAnnual Recovery31%Revenue Increase
+28%Revenue Increase
Cognitive / Memory Clinic
A cognitive/memory clinic was documenting dementia care without billing the 60-minute 99483 cognitive impairment assessment or 99497 advance care planning. MedFactor implemented documentation templates that captured both layered services.
$190KAnnual Savings28%Revenue Increase
No matter where your geriatrics practice operates, our team understands the payer landscape and regulatory requirements in your region.
Deep coding knowledge across Medicare, Medicare Advantage, Medicaid, and commercial payers for geriatrics services.
HCC risk-adjustment capture and RAF optimization applied correctly across all Medicare Advantage plans.
Time-based care-management coverage and 99492-99494 rules applied correctly across all 50 states.
Home visit (99341-99350), assisted-living, and skilled-nursing facility billing coordination across regions.
Common questions from geriatrics practices considering MedFactor’s specialty RCM services.
What are the required elements of an Annual Wellness Visit (AWV)?
The initial Annual Wellness Visit (G0438) and subsequent AWV (G0444) require a health risk assessment, medical/family history, measurement of blood pressure/BMI/weight, cognitive screening, review of risk factors and current prescriptions, and establishment of a written personalized 5-year care plan. The first AWV (G0438) includes the initial preventive physical exam components, while G0444 is billed annually thereafter. We verify every required element is documented per the CMS template before submitting the claim, so the AWV is paid rather than denied for missing-element gaps — the most common AWV denial reason.
How does Chronic Care Management (CCM) billing and time documentation work?
Chronic Care Management 99490 is billed once per calendar month per patient with two or more chronic conditions expected to last at least 12 months, requiring at least 20 minutes of clinical staff time directed by a physician that month, plus a documented care plan. The 99439 add-on is billed for each additional 20 minutes of care management beyond the base. Complex CCM (99437) is billed in 30-minute increments for higher-complexity patients. Time must be logged and the care plan accessible. We validate the monthly time log and care-plan documentation before billing each CCM month, and capture 99439 add-ons whenever the documented time exceeds 20 minutes — the most common way CCM revenue is lost.
How is Behavioral Health Integration (BHI) coded alongside CCM?
BHI is billed under a psychiatric collaborative care model or behavioral care management framework. 99484 is the base BHI code for behavioral health integration, with 99492 billed for the first 70 minutes of behavioral care management in the first month, 99493 for the first 60 minutes in months 2-6, and 99494 as an add-on for each additional 30 minutes. BHI can be stacked alongside CCM when the patient has both chronic medical and behavioral conditions, because BHI addresses the behavioral pathway separately. We document behavioral care-management time and the psychiatric clinical pathway so BHI is captured alongside CCM rather than absorbed into the CCM time.
When and how is the 99483 cognitive impairment assessment billed?
Cognitive impairment assessment (99483) is billed for a 60-minute clinical visit that includes a cognitive assessment, development of a care plan, and discussion with the patient and/or caregiver. It is typically billed once per patient and requires documentation of all three components — assessment, care plan, and caregiver input. It supports dementia ICD-10 codes (F01 vascular dementia, F03 unspecified dementia, G30 Alzheimer’s) and R54 age-related cognitive decline. We use documentation templates that capture the assessment tool used, the care plan, and the caregiver discussion so the full 99483 requirements are met rather than documenting cognition informally and leaving the code unbilled.
How do Transitional Care Management (99495/99496) visit windows work?
Transitional Care Management is billed once per 30-day post-discharge period per patient. 99496 (high complexity) requires an interactive contact within 2 business days of discharge and a face-to-face visit within 7 days of discharge. 99495 (moderate complexity) requires an interactive contact within 2 business days and a face-to-face visit within 14 days of discharge. Both require medication reconciliation and a non-face-to-face care-management component. We ingest the discharge feed to trigger visit-window alerts, capture medication reconciliation, and ensure the F2F visit is scheduled within the code-specific window so TCM is billed rather than missed when the visit slips outside the period.
How is advance care planning (99497) billed and stacked?
Advance care planning 99497 is billed for the first 30 minutes of a face-to-face conversation between the physician and patient (and/or caregiver) about goals of care, advance directives, and end-of-life preferences. 99498 is the subsequent add-on for each additional 30 minutes. It can be stacked with the AWV, cognitive assessment 99483, or a problem E/M (with modifier 25 where required) when the goals-of-care discussion is separately documented. Medicare allows voluntary advance care planning as a separate service. We document the time, the discussion content, and the resulting plan so 99497 is captured whenever goals-of-care conversations occur — frequently delivered but rarely billed without dedicated documentation.
MedFactor applies the same code-level precision across the full practice spectrum. See how we bill these related specialties.
Internal Medicine
Family Medicine
Hospice & Palliative
All Specialties →
CPT®, ICD-10, HCPCS, and modifier codes referenced on this page reflect the current code sets and are subject to annual updates — always verify against the current-year fee schedule before submission. KPIs and case-study figures shown are representative benchmarks, not guarantees of individual practice results.
The rules on this page are published somewhere official. These are the ones worth reading yourself.
The published Medicare rates and payment rules behind most of the codes on this page.
The rules governing referrals between a practice and its own ancillary services.
The coding and billing standards body whose credentials most billers and coders hold.
Enforcement guidance on billing compliance, and the arrangements that attract scrutiny.
The procedure-to-procedure and medically unlikely edits behind most bundling denials.
The specialty society behind annual wellness visit and cognitive assessment guidance.
Your geriatrics practice deserves billing partners who know AWV element documentation, CCM 99490/99439 time-stacking, BHI behavioral integration, 99483 cognitive capture, and modifier 25 same-day rules — and code every claim correctly. Let MedFactor show you what specialty RCM can do.
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