Family Practice Billing Cheat Sheet (2026)
The biggest leak in family practice is the same-day visit: a wellness exam plus a problem addressed in the same appointment, billed as only one. The second biggest is an age-mismatched preventive code. This page covers the age-banded preventive set, the modifier 25 split-visit rule, and vaccine administration capture.
Quick reference for family practice billers. Last updated .
Top Family Practice CPT Codes & 2026 Medicare Allowables
| Code | Description | Non-Facility | Facility | Total RVU |
|---|---|---|---|---|
| 99203 | New patient office visit, low complexity | $117.57 | $71.48 | 3.52 |
| 99204 | New patient office visit, moderate complexity | $177.36 | $116.90 | 5.31 |
| 99205 | New patient office visit, high complexity | $236.81 | $160.32 | 7.09 |
| 99213 | Established patient office visit, low complexity | $95.19 | $57.45 | 2.85 |
| 99214 | Established patient office visit, moderate complexity | $135.61 | $84.50 | 4.06 |
| 99215 | Established patient office visit, high complexity | $192.39 | $125.59 | 5.76 |
| 99395 | Preventive visit, established patient, 18-39 years | $121.58 | $74.82 | 3.64 |
| 99396 | Preventive visit, established patient, 40-64 years | $128.93 | $81.16 | 3.86 |
| 99397 | Preventive visit, established patient, 65+ years | $138.95 | $85.17 | 4.16 |
| 99391 | Preventive visit, established patient, infant/early childhood | $102.54 | $58.45 | 3.07 |
| 99490 | Chronic care management, first 20 minutes per month | $66.13 | $43.76 | 1.98 |
| 69210 | Removal of impacted cerumen, one or both ears | $47.76 | $27.05 | 1.43 |
National 2026 Medicare Physician Fee Schedule estimates (total RVU multiplied by the conversion factor). These are adjusted by state locality. See the per-state table on the Family Practice billing services page.
Modifiers That Prevent Family Practice Denials
A significant, separately identifiable problem-oriented E/M on the same day as a preventive visit or a minor procedure. This is the core family-practice modifier.
A preventive service with the cost share waived under the ACA, which separates it from a diagnostic version of the same test.
A distinct service unbundled from a same-day procedure when NCCI would combine them.
A synchronous telehealth E/M. Match the payer's place-of-service policy.
An unrelated E/M during the global period of a prior minor procedure.
A repeat procedure or test by the same physician on the same day, such as a repeat ECG.
Top Family Practice Denials → Quick Fix
Match the code to patient age. For established patients, 99395 is 18 to 39, 99396 is 40 to 64, and 99397 is 65 and up. A mismatched age code is rejected.
Append modifier 25 to the problem E/M billed alongside the preventive code, and document the problem evaluation separately from the wellness exam.
Bill the product (the 9xxxx vaccine code) and the administration (90460, 90471, or 90472) as separate lines. The administration is separately payable and frequently dropped.
Pair screening services with the payer's covered screening diagnosis. A screening code with a symptomatic or unsupported diagnosis denies for medical necessity.
Verify the last preventive date before scheduling. Most payers allow one per 12-month period. Bill the excess as a problem visit if clinically appropriate.
NCCI Bundling Watch-Outs
Code pairs from this specialty's set that carry NCCI edits. Billing both without a justified modifier triggers a bundling denial.
| Code | Bundles With | Rationale |
|---|---|---|
| 99203 | 0362T | Misuse of Column Two code with Column One code |
| 99203 | 0373T | Misuse of Column Two code with Column One code |
| 99204 | 0362T | Misuse of Column Two code with Column One code |
| 99204 | 0373T | Misuse of Column Two code with Column One code |
| 99205 | 0362T | Misuse of Column Two code with Column One code |
| 99205 | 0373T | Misuse of Column Two code with Column One code |
| 99213 | 0362T | Misuse of Column Two code with Column One code |
| 99213 | 0373T | Misuse of Column Two code with Column One code |
Documentation That Holds Up on Appeal
An age-appropriate comprehensive history and exam, and the age band. The code is age-driven.
A separate problem-oriented note (HPI, exam, MDM) distinct from the wellness documentation, to support modifier 25.
Each product, the route, and counseling (for 90460), to support both the product and administration codes.
MDM elements or total time on the date of service supporting the level billed.
Impacted cerumen, the instrumentation used, and that the provider performed it, not lavage by staff.
Revenue Family Practice Practices Leave on the Table
Not billing the same-day problem visit with modifier 25 alongside the preventive exam. This is the largest family-practice leak.
Dropping vaccine administration codes and billing only the product.
Enrolling few patients in CCM (99490) despite a chronic-disease-heavy panel.
Down-coding established visits to 99213 out of audit fear when MDM or time supports 99214.
Family Practice Billing FAQ
Can I bill a problem visit and a physical the same day?
Yes. Bill the age-appropriate preventive code plus the problem E/M with modifier 25, and keep the two evaluations documented separately. This split visit is the most commonly missed family-practice revenue.
Which preventive code by age?
For established patients, the range runs from 99391 in the early childhood bands up to 99395 for 18 to 39, 99396 for 40 to 64, and 99397 for 65 and up. New patients use the 99381 to 99387 series. An age-mismatched code denies.
Do I bill vaccine administration separately?
Always. The vaccine product and its administration (90460, 90471, or 90472) are separate, separately payable lines. Billing only the product forfeits the administration fee on every dose.
How do I prevent screening-service denials?
Use the payer's covered screening diagnosis with the screening code. If the visit became diagnostic because a symptom was found, code it as a problem service instead. Mixing the two causes medical-necessity denials.
Stop Losing Family Practice Revenue to Preventable Denials
Our AAPC-certified family practice coders apply every rule on this sheet to your claims. Call 888-701-6090 for a free billing assessment.