CMS Physician Fee Schedule
The published Medicare rates and payment rules behind most of the codes on this page.
Family medicine billing hinges on preventive visit ladders (99381–99397 by age), Annual Wellness Visits (G0438/G0444), and Chronic Care Management (99490/99439). Add same-day modifier 25 rules when a problem E/M accompanies a preventive visit, immunization administration 90460–90474, and HCC risk-adjustment capture — and general billers miss revenue on every panel. MedFactor delivers family-medicine-specific RCM that protects every claim.
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Preventive & Chronic Care — RCM PanelLive
Preventive Visit Ladder (CPT by Age)
New
Est.
<1X99381O99391
1-4X99382O99392
5-11X99383O99393
12-17X99384O99394
18-39X99385O99395
40-64X99386O99396
65+X99387O99397
0%Clean Claim Rate
0%Denial Reduction
0dDays in A/R
From primary care and preventive wellness to chronic disease management and rural community health, we tailor billing to the coding rules of every family medicine practice type.
Primary Care
Comprehensive primary care E/M, preventive visits, and chronic disease management for all ages with age-based coding accuracy.
Preventive
Annual Wellness Visits (G0438/G0444), preventive exams 99381–99397, and screenings with HRA and risk-stratification documentation.
Chronic Care
Chronic Care Management 99490/99439, Principal Care Management, and behavioral health integration for multi-condition panels.
Lifespan Mix
Age-based preventive codes, immunization administration 90460–90474, and well-child and well-adult visits across the full age spectrum.
Geriatric
Transitional Care Management 99495/99496, Annual Wellness Visits, and home-based chronic care for senior panels.
Community
FQHC-style encounter billing, sliding-scale capture, and HCC risk-adjustment for community and rural family medicine practices.
Family medicine revenue lives in three layered tracks — age-band preventive visits (99381–99397), Annual Wellness Visits (G0438/G0444), and Chronic Care Management (99490/99439/99437). When a problem E/M occurs same-day as a preventive visit, modifier 25 must be appended or the problem E/M is denied as bundled. This is the largest source of family medicine revenue leakage.
One visit can carry a preventive code, an AWV, and a CCM layer — but only when each element is documented and the same-day problem E/M is reported with modifier 25.
Base — Preventive VisitPreventive Medicine Visit, New Patient (by age)99381–99387
Established Patient Preventive (by age)Same wellness visit, established patient age bands99391–99397
Initial Annual Wellness Visit (AWV)First AWV — HRA, risk assessment, care planG0438
Subsequent AWVAnnual repeat AWV after the initial visitG0444
Annual alcohol / tobacco screeningScreening captured during the AWV encounterG0442
CCM — base, first 30 min / monthChronic Care Management base code per patient99490
CCM — additional 20 minAdd-on time beyond the 99490 base99439
CCM — additional 30 minExtended CCM add-on track99437
Modifier 25 — problem E/M same day as preventiveSeparately reportable; without mod 25 the problem E/M bundles into the preventive visit· 25
Our focus: We bill each preventive visit at the correct age-band code (99381–99397), layer the AWV (G0438/G0444) and CCM (99490/99439/99437) where documented, and append modifier 25 when a separately identifiable problem E/M occurs same-day — capturing the problem E/M revenue instead of letting it bundle into the preventive visit.
Family medicine billing is governed by preventive ladders, AWV element documentation, CCM time rules, and same-day modifier 25 that general billing companies cannot navigate effectively.
Problem E/M billed with a preventive visit without modifier 25, losing the separate E/M payment.
Severity
Annual Wellness Visit denied when the HRA, risk assessment, or personalized care plan elements are incomplete.
Severity
Chronic Care Management denied for missing care plan, the 20-minute time threshold, or patient consent.
Severity
Immunization administration and vaccine product codes mismatched, or the vaccine product not captured separately.
Severity
Chronic condition diagnoses not documented to specificity, losing HCC risk-adjustment value on the panel.
Severity
Telehealth E/M billed without the correct modifier 95/GT or outside payer coverage and originating-site rules.
Severity
Quick reference for the most frequently used CPT, HCPCS, ICD-10, and modifier codes in family medicine billing and coding.
CPT / HCPCS
ICD-10 Codes
Modifiers
| Code | Description | Common Use |
|---|---|---|
| 99381 | Preventive visit, new patient, infant | Age-band preventive ladder (new) |
| 99386 | Preventive visit, new patient, 40–64 | Adult preventive exam |
| 99387 | Preventive visit, new patient, 65+ | Geriatric preventive exam |
| 99391 | Preventive visit, established, infant | Age-band preventive ladder (established) |
| 99396 | Preventive visit, established, 40–64 | Established adult preventive |
| 99397 | Preventive visit, established, 65+ | Established geriatric preventive |
| G0438 | Initial Annual Wellness Visit | First AWV with HRA & care plan |
| G0444 | Subsequent Annual Wellness Visit | Annual repeat AWV |
| G0442 | Annual alcohol / tobacco screening | Screening captured during AWV |
| 99490 | Chronic Care Management, first 30 min/mo | CCM base code per patient |
| 99439 | CCM, additional 20 min/mo | CCM add-on time |
| 99437 | CCM, additional 30 min/mo | Extended CCM add-on |
| 99495 | Transitional Care Management, moderate | TCM within 14 days of discharge |
| 99496 | Transitional Care Management, high | TCM within 7 days of discharge |
| 90460 | Immunization admin + counseling, first | Pediatric vaccine administration |
| 90471 | Immunization admin, one vaccine | Single vaccine administration |
| 90472 | Immunization admin, each additional | Additional vaccine same encounter |
| 90473 | Oral immunization admin, first | Oral vaccine administration |
| 90474 | Oral immunization admin, each additional | Additional oral vaccine |
| Code | Description | Clinical Context |
|---|---|---|
| E10 | Type 1 diabetes mellitus | Chronic condition / CCM & HCC |
| E11 | Type 2 diabetes mellitus | Chronic condition / CCM & HCC |
| I10 | Essential (primary) hypertension | Most common chronic diagnosis |
| E78 | Disorders of lipoprotein metabolism | Hyperlipidemia / preventive screening |
| J45 | Asthma | Chronic respiratory condition / CCM |
| M54 | Dorsalgia / back pain | Musculoskeletal complaint |
| F32 | Major depressive disorder, single episode | Behavioral health / HCC |
| Z00 | Encounter for general adult medical exam | Preventive visit indicator |
| Z79 | Long term (current) drug therapy | Insulin Z79.4, anticoagulants Z79.01 |
| Z23 | Encounter for immunization | Vaccine administration indicator |
| Z01.89 | Encounter for other specified exam | Other screening / administrative |
| Modifier | Description | Family Medicine Application |
|---|---|---|
| 25 | Significant, separately identifiable E/M same day | Problem E/M with same-day preventive visit |
| 33 | Preventive service | Optional marker for preventive services (some payers) |
| 24 | Unrelated E/M during post-op global | Unrelated E/M in a postoperative global period |
| 95 | Synchronous telehealth | Telehealth E/M via real-time audio/video |
| GT | Telehealth (legacy) | Telehealth on some Medicaid / state payers |
| GC | Teaching physician service | Teaching physician involvement in resident visits |
| 52 | Partial / reduced service | Reduced preventive service (not all elements) |
| GA | Waiver of liability statement | ABN on potentially non-covered service |
Comprehensive revenue cycle management designed specifically for family medicine and primary care practices.
Specialty coders handle preventive ladders, AWV, CCM, immunization administration, and modifier 25 same-day rules with accuracy.
AWV element, CCM time/care-plan, and modifier 25 denials defended with procedural documentation and appeals.
Pre-auth for advanced imaging, certain medications, and procedures common to primary care workflows.
Prioritized follow-up on aged preventive, AWV, CCM, and immunization claims with strategic payer escalation.
Regular audits focused on modifier 25 same-day, AWV element completeness, CCM time documentation, and HCC capture.
Real-time dashboards tracking preventive visit rates, AWV completion, CCM enrollment, and HCC risk-adjustment capture.
Understanding the most common denial reasons is the first step to preventing them on preventive, AWV, CCM, and immunization claims.
Problem E/M bundled into a preventive visit without modifier 25, losing the separate E/M payment.
Modifier 25 appended when a separately identifiable problem E/M occurs same-day as a preventive visit.
Annual Wellness Visit denied when the HRA, risk assessment, or personalized care plan elements are incomplete.
AWV element checklist verifying HRA, risk stratification, and personalized care plan before submission.
Chronic Care Management denied for missing care plan, the 20-minute time threshold, or patient consent.
CCM documentation protocol with care plan, timed minutes, and consent captured on every CCM claim.
Immunization administration code and vaccine product code mismatched, or the product not captured separately.
Immunization administration + vaccine product pairing verified per claim with the correct 90460–90474 admin code.
Identifying and plugging these common revenue leakage points can significantly improve your practice’s bottom line.
Age-band preventive visit billed at the wrong code, losing the correct preventive payment.
Eligible patients not invited for the Annual Wellness Visit, losing G0438/G0444 revenue.
Eligible chronic-care patients not enrolled in CCM 99490, losing monthly management revenue.
Chronic conditions coded to unspecified levels, losing risk-adjustment value.
See how family-medicine-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 family medicine billing operations, preventive/AWV/CCM capture, and revenue cycle baseline.
2WEEK 3–4
EMR integration, dedicated family medicine billing team, and payer enrollment verification.
3WEEK 5–8
Full billing with real-time claim submission, modifier verification, and denial prevention protocols.
4WEEK 9–12
Performance review against baseline, workflow optimization, and documented revenue improvement.
How our family-medicine-specific approach compares to in-house billing and general medical billing companies.
| Capability | In-House Team | General Billing Co. | MedFactor Family Med |
|---|---|---|---|
| Preventive visit age-band capture | Inconsistent | ✕ | ✓ |
| AWV element documentation (HRA / care plan) | Inconsistent | Partial | ✓ |
| CCM care-plan & 20-min time tracking | ✕ | Partial | ✓ |
| Modifier 25 same-day problem E/M | ✕ | ✕ | ✓ |
| Immunization admin + vaccine product pairing | Manual | Partial | ✓ |
| HCC risk-adjustment capture | ✕ | Partial | ✓ |
| Telehealth modifier 95 / GT rules | Inconsistent | Partial | ✓ |
| Preventive / AWV completion reporting | ✕ | ✕ | ✓ |
| Dedicated family medicine billing team | ✕ | ✕ | ✓ |
Our team combines deep family medicine and primary care billing expertise with the technology and processes to deliver consistent, measurable results for preventive, chronic-care, and lifespan practices.
Discover exactly where your family medicine practice is losing revenue. Our no-obligation audit analyzes your preventive visit capture, AWV element documentation, CCM claims, and modifier 25 compliance.
Schedule Your Free Audit
22%Average Revenue ImprovementPractices see an average 22% improvement in net collections within the first year.
2 WeeksAudit Completion TimeComplete billing and coding audit delivered within 10 business days.
Real results from family medicine practices that partnered with MedFactor for specialty revenue cycle management.
$410KRevenue Recovered
Primary Care
A multi-provider family medicine practice was under-coding preventive visits and dropping same-day problem E/M modifier 25. MedFactor implemented age-band preventive capture and modifier 25 protocols, recovering substantial revenue in eight months.
45%Denial Reduction17dA/R Reduced
$320KAnnual Capture
Preventive / Chronic Care
A preventive-care-focused practice was missing AWV element documentation and CCM enrollment. MedFactor built AWV checklists and CCM documentation protocols, recovering AWV and CCM revenue across the panel.
$320KAnnual Recovery31%Revenue Increase
+27%Revenue Increase
Rural Community Clinic
A rural community health clinic was losing HCC risk-adjustment value and immunization product capture. MedFactor implemented HCC specificity coding and immunization admin/product pairing, protecting community-health revenue.
$190KAnnual Savings27%Revenue Increase
No matter where your family medicine practice operates, our team understands the payer landscape and regulatory requirements in your region.
Deep coding knowledge across Medicare, Medicaid, and all major commercial payers for family medicine services.
Annual Wellness Visit and preventive service coverage applied correctly across all 50 states.
Telehealth modifier 95/GT and CCM rules coordinated across state Medicaid programs.
FQHC encounter billing and rural family medicine coverage aligned with state and federal programs.
Common questions from family medicine practices considering MedFactor’s specialty RCM services.
How do preventive visits and same-day modifier 25 work?
Preventive medicine visits are billed by age band — new patients 99381–99387 and established patients 99391–99397 — and cover the wellness exam, screening, and counseling. When a separately identifiable problem E/M (such as an acute illness or chronic-condition flare) is addressed during the same visit as a preventive exam, the problem E/M is billed with modifier 25 appended. Without modifier 25, the problem E/M is denied as bundled into the preventive visit and that revenue is lost. We verify the documentation supports a separately identifiable problem E/M and append modifier 25 so the problem E/M is paid separately from the preventive visit.
How is the Annual Wellness Visit (AWV) coded?
The Initial Annual Wellness Visit is billed with HCPCS code G0438 and includes a health risk assessment (HRA), medical/family history, risk stratification, and a personalized care plan. Subsequent annual AWVs are billed with G0444 and update the HRA and care plan each year. The AWV is distinct from a preventive physical exam (99381–99397) — the AWV is a Medicare benefit focused on risk and planning rather than a hands-on physical. We use an AWV element checklist to confirm the HRA, risk assessment, and personalized care plan are all documented before submission so the AWV is not denied for missing elements.
What documentation does Chronic Care Management (CCM) require?
Chronic Care Management base code 99490 covers the first 30 minutes of clinical staff time per calendar month directed by a physician for a patient with two or more chronic conditions expected to last at least 12 months. Add-on code 99439 bills each additional 20 minutes beyond the base, and 99437 bills each additional 30 minutes for extended management. CCM requires an electronic care plan, patient consent, and 24/7 access to care. The care plan must document the conditions, treatments, and goals, and time must be logged and total at least the threshold minutes.
We capture the care plan, timed minutes, and consent on every CCM claim so 99490 and its add-ons are paid rather than denied for missing documentation.
How do immunization administration and vaccine product codes work?
Immunization claims pair an administration code with a vaccine product code. Administration codes include 90460 (with counseling, first component), 90471 (one vaccine, without counseling), 90472 (each additional vaccine), and 90473/90474 for oral administration. The vaccine product itself is billed on a separate line with its product code (CPT 90xxx or a HCPCS J-code). Mismatched admin and product codes — or omitting the product code — cause denials and lost product revenue. We pair the correct administration code with the correct vaccine product code on every immunization claim so both the admin fee and the vaccine product are captured.
How is telehealth billed in family medicine?
Telehealth E/M visits are billed with the appropriate E/M code plus modifier 95 for synchronous audio-video telehealth on most payers; some Medicaid and state programs still use modifier GT. Payer coverage, originating-site rules, and eligible E/M levels vary, so we verify each payer’s telehealth policy before submission and apply the correct modifier (95 vs GT) per payer. We also confirm the visit meets the payer’s telehealth documentation requirements, including consent and the modality used, so telehealth E/M is paid rather than denied for a missing or wrong modifier.
What is HCC risk-adjustment capture and why does it matter?
Hierarchical Condition Category (HCC) risk-adjustment ties a practice’s Medicare reimbursement to the documented chronic conditions of its patient panel. Conditions like diabetes (E10/E11), hypertension (I10), COPD, depression (F32), and heart failure each carry HCC weight, but only when coded to the supported specificity each year. Unspecified or under-documented diagnoses lose risk-adjustment value and lower the practice’s per-member reimbursement. We audit the problem-oriented visit notes for documented chronic conditions, code them to the highest supported specificity, and capture long-term medication status (such as Z79.4 for insulin) so the panel’s HCC risk score accurately reflects the care being delivered.
MedFactor applies the same code-level precision across the full practice spectrum. See how we bill these related specialties.
Internal Medicine
Pediatrics
Geriatrics
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 covering primary care coding, CCM and preventive services rules.
Your family medicine practice deserves billing partners who know preventive ladders, AWV, CCM, and same-day modifier 25 — and code every claim correctly. Let MedFactor show you what specialty RCM can do.
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