Family Medicine Billing & Coding Guide
AWVs, chronic care management, transitional care management. The most-billed E/M family in the country.
Common Family Medicine CPT Codes
Ranked by claim frequency, with current MPFS work RVUs and global periods.
| Code | Description | Work RVU | Total RVU | Global |
|---|---|---|---|---|
| 99214 | Office o/p est mod 30 min | 1.92 | 4.06 | XXX |
| 99215 | Office o/p est hi 40 min | 2.80 | 5.76 | XXX |
| 99213 | Office o/p est low 20 min | 1.30 | 2.85 | XXX |
| 99395 | Prev visit est age 18-39 | 1.75 | 3.64 | XXX |
| 99396 | Prev visit est age 40-64 | 1.90 | 3.86 | XXX |
| 99397 | Per pm reeval est pat 65+ yr | 2.00 | 4.16 | XXX |
| 99385 | Prev visit new age 18-39 | 1.92 | 4.03 | XXX |
| 99386 | Prev visit new age 40-64 | 2.33 | 4.66 | XXX |
| 99387 | Init pm e/m new pat 65+ yrs | 2.50 | 5.05 | XXX |
| 99490 | Chrnc care mgmt staff 1st 20 | 1.00 | 1.98 | XXX |
| 99491 | Chrnc care mgmt phys 1st 30 | 1.50 | 2.67 | XXX |
| 99457 | Rpm tx mgmt 1st 20 min | 0.61 | 1.55 | XXX |
| 99458 | Rpm tx mgmt ea addl 20 min | 0.61 | 1.24 | ZZZ |
| 96372 | Ther/proph/diag inj sc/im | 0.17 | 0.46 | XXX |
| 90471 | Immunization admin | 0.17 | 0.66 | XXX |
| 90472 | Immunization admin each add | 0.15 | 0.48 | ZZZ |
| 69210 | Remove impacted ear wax uni | 0.59 | 1.43 | 000 |
| 17110 | Destruction b9 les up to 14 | 0.68 | 3.33 | 010 |
What Family Medicine practices are leaving on the table
High-value services that consistently get under-billed across the specialty. Each one is rooted in current 2026 fee schedule and policy updates.
Preventive + problem-oriented same-day billing — 60% of family practices don't bill both when they should. If a patient mentions a new symptom during their annual, that's a separately billable E/M ($92-186 additional).
CCM for chronic patients — average family practice has 300-500 Medicare patients with 2+ chronic conditions. At $42-74/patient/month, that's $150K-350K/year in new revenue.
In-office procedures — cerumen removal ($45), skin biopsies ($90-150), lesion destructions ($70-120). Many practices refer these out unnecessarily.
Tobacco cessation (99406/99407) — billable every visit, Medicare covers 8 sessions/year. Takes 3-10 minutes. Most practices never bill it.
Depression screening (96127) — $5-8 per screening, billable annually with AWV. Takes 2 minutes. Volume adds up across all patients.
Immunization admin optimization — 90471 (first vaccine) + 90472 (each additional). When giving 3 vaccines = 90471 + 90472x2. Many practices only bill 90471.
Code pairs that auto-bundle to CO-97
From the National Correct Coding Initiative for Family Medicine. The rationale tells you when a modifier legitimately bypasses the edit and when it cannot.
Preventive and problem-oriented E/M on same day: bill both only with modifier 25 on the E/M AND separate documentation. Many payers deny this.
Private preventive exam + Medicare AWV: cannot bill both. AWV is Medicare-specific; 99395 is commercial.
Immunization admin bundles with therapeutic injection admin if same encounter — use modifier 59 if different drug/site.
17111 is add-on to 17110. 17110 = first 14 lesions, 17111 = each additional 15. Cannot bill 17111 alone.
11103 is add-on to 11102. 11102 = first biopsy, 11103 = each additional. Cannot bill 11103 alone.
Modifier Guidance for Family Medicine
When each modifier legitimately applies in this specialty, with denial-pattern context and audit-defense documentation.
Critical for family medicine — most visits involve E/M + procedure. Document: 'In addition to the preventive exam, a separately identifiable problem was evaluated: [specific condition].'
Use when performing multiple procedures at different sites. Example: biopsy on arm + destruction on back = 11102 + 17110-59.
Repeat procedure by same physician. Example: second cerumen removal on same day (different ear).
Required for bilateral procedures. Cerumen removal bilateral = 69210-LT + 69210-RT-50 (or 69210 with modifier 50).
Documentation requirements
What needs to live in the encounter note for these codes to survive a payer audit.
- Preventive + problem E/M same day: Two separate notes — one for the preventive exam, one for the problem-oriented E/M. Can be in the same encounter note but clearly delineated.
- Cerumen removal (69210): Document the impaction (not just 'wax present'), that it's affecting hearing or exam, and the method of removal.
- Skin biopsy (11102/11103): Document lesion size, location, clinical appearance, why biopsy is needed (suspected malignancy, changing lesion, etc).
- Immunizations: Document vaccine name, manufacturer, lot number, expiration date, site, route, VIS date given, and patient/parent consent.
OIG and audit triggers in Family Medicine
Patterns that show up in OIG Work Plans, RAC audits, and CERT improper payment reviews. Build internal compliance checks around these.
Preventive vs problem coding confusion: If the REASON for the visit is preventive, use 99395/G0439 as primary. If a new problem is also addressed, ADD 99214-25. Don't flip them.
Wrong ICD-10 for preventive labs: Use Z00.00 (encounter for general exam) or Z13.x (screening codes), NOT the chronic condition code for a screening test.
Cerumen removal underbilling: 69210 pays ~$45. Many practices don't bill it because they consider it part of the exam. It's separately billable if the impaction is documented.
Immunization admin missed: Giving a flu shot during a visit? Bill 90471 + vaccine code. Giving flu + Tdap + pneumococcal? Bill 90471 + 90472 + 90472 + 3 vaccine codes.
Time-based E/M not captured: 2021 guidelines allow E/M based on TOTAL time. A 40-minute visit with complex counseling = 99215, even if MDM is only moderate.
Missing AWV components: Medicare requires HRA, cognitive assessment, fall risk, depression screen, and personalized prevention plan. Missing any = audit risk.
Payer-specific billing notes
Where the major payers diverge from generic Medicare rules in Family Medicine.
ME Medicare +
AWV covered annually. Preventive codes (99381-99397) NOT covered by Medicare — use G0438/G0439 instead. IPPE (Welcome to Medicare) only once within first 12 months.
UN UnitedHealthcare +
Covers preventive + problem-oriented same day with modifier 25. Requires specific documentation format for combined visits.
AE Aetna +
Most plans cover annual preventive. Will deny preventive labs if wrong ICD-10 (use Z-codes). Prior auth rarely required for family medicine.
BC BCBS +
Preventive coverage varies by state plan. Some plans limit destructions to 14/visit. Immunization admin may require specific NDC codes.
ME Medicaid +
Coverage varies by state. Many state Medicaid programs don't cover AWV. EPSDT for pediatric patients covers comprehensive preventive services.
Standard Family Medicine coding workflow
1. Determine visit type: preventive, problem-oriented, or both. 2. For preventive: select age-appropriate code (99391-99397 for commercial, G0438/G0439 for Medicare). 3. If problem also addressed: add E/M code with modifier 25 + separate documentation. 4. Bill all procedures performed (biopsies, destructions, injections) with appropriate modifiers. 5. Bill immunization admin + vaccine codes separately. 6. Check CCM/RPM eligibility for chronic patients. 7. Verify ICD-10 codes — use Z-codes for preventive, active diagnosis codes for problem-oriented.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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