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Family Practice Billing Services

Family practice is the broadest scope in medicine. Your providers see patients from newborns to seniors, handle preventive care alongside acute illness, and manage chronic conditions across every organ system. The billing complexity matches the clinical breadth.

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300+ Practices
99213Office Visit
99392Preventive
99490CCM
90471Vaccines

Why Family Practice Billing Requires Specialty Expertise

Family practice billing covers the full age spectrum with preventive visits (99381-99397), problem-oriented visits (99202-99215), chronic care management, immunization administration, and procedures ranging from skin biopsies to joint injections. The challenge is capturing all billable services during multi-reason visits and correctly separating preventive from problem-oriented care.

Common Family Practice CPT Codes

Our coders handle these family practice codes daily. This is not an exhaustive list.

Code
Description
99203
New patient office visit, low complexity
99204
New patient office visit, moderate complexity
99205
New patient office visit, high complexity
99213
Established patient office visit, low complexity
99214
Established patient office visit, moderate complexity
99215
Established patient office visit, high complexity
99395
Preventive visit, established patient, 18-39 years
99396
Preventive visit, established patient, 40-64 years
99397
Preventive visit, established patient, 65+ years
99391
Preventive visit, established patient, infant/early childhood
99490
Chronic care management, first 20 minutes per month
69210
Removal of impacted cerumen, one or both ears

2026 Medicare Allowables for Family Practice CPT Codes by State

Medicare reimbursement for family practiceprocedures is not a single national number. Each code's allowable is adjusted by your state's Geographic Practice Cost Index (GPCI) and processed under that state's Medicare Administrative Contractor (MAC), so the same family practice CPT code pays a different amount in California than it does in Texas or Florida. The table below shows the 12 core family practicecodes our coders bill priced at each state's 2026 locality. The non-facility figure is what an office-based practice collects. The facility figure applies when the service is performed in a hospital-based setting.

Commercial carriers in each state typically reimburse above these Medicare benchmarks and state Medicaid below them, but the Medicare allowable is the contracting anchor every payer negotiation starts from. Compare any individual code across all states with our Medicare fee calculator by state.

2026 Medicare non-facility allowable for Family Practice CPT codes across high-volume states
CodeFamily Practice ProcedureCATXFLNYPAILOHGANCMI
99203New patient office visit, low complexity$127.81$116.57$122.82$128.82$117.22$120.64$112.50$116.00$111.70$116.17
99204New patient office visit, moderate complexity$191.92$175.99$185.22$193.89$177.00$182.18$170.25$175.27$168.94$175.59
99205New patient office visit, high complexity$255.27$234.93$248.55$259.15$236.48$244.53$227.52$234.39$225.24$235.13
99213Established patient office visit, low complexity$104.31$94.46$98.20$103.97$94.79$96.44$90.97$93.60$90.84$93.44
99214Established patient office visit, moderate complexity$148.01$134.59$140.26$148.05$135.13$137.84$129.83$133.55$129.44$133.44
99215Established patient office visit, high complexity$209.36$190.98$199.34$209.96$191.83$196.01$184.45$189.69$183.70$189.65
99395Preventive visit, established patient, 18-39 years$132.89$120.72$125.25$132.54$121.14$123.12$116.44$119.65$116.27$119.45
99396Preventive visit, established patient, 40-64 years$140.63$128.04$132.93$140.48$128.52$130.73$123.61$126.98$123.36$126.81
99397Preventive visit, established patient, 65+ years$151.99$137.97$142.97$151.43$138.43$140.53$133.05$136.70$132.94$136.43
99391Preventive visit, established patient, infant/early childhood$112.87$101.76$105.25$111.93$102.03$103.31$97.85$100.64$97.95$100.33
99490Chronic care management, first 20 minutes per month$71.83$65.68$68.45$72.07$65.97$67.35$63.51$65.25$63.25$65.23
69210Removal of impacted cerumen, one or both ears$52.11$47.31$50.06$52.51$47.58$49.09$45.54$47.06$45.20$47.15

Full Family Practice fee detail by state

2026 Medicare allowables for family practice CPT codes in California, processed under Noridian Healthcare Solutions (Jurisdiction E). See California medical billing.

2026 Medicare allowables for Family Practice CPT codes in California
CodeDescriptionNon-FacilityFacility
99203New patient office visit, low complexity$127.81$73.27
99204New patient office visit, moderate complexity$191.92$120.39
99205New patient office visit, high complexity$255.27$164.77
99213Established patient office visit, low complexity$104.31$59.65
99214Established patient office visit, moderate complexity$148.01$87.54
99215Established patient office visit, high complexity$209.36$130.32
99395Preventive visit, established patient, 18-39 years$132.89$77.56
99396Preventive visit, established patient, 40-64 years$140.63$84.11
99397Preventive visit, established patient, 65+ years$151.99$88.36
99391Preventive visit, established patient, infant/early childhood$112.87$60.70
99490Chronic care management, first 20 minutes per month$71.83$45.35
69210Removal of impacted cerumen, one or both ears$52.11$27.61

Source: 2026 Medicare Physician Fee Schedule, locality-adjusted by state MAC. Figures are for reference and contracting benchmarks, not a guarantee of payment.

Family Practice Billing Challenges We Solve

Common billing problems in family practice and how our team handles them.

Preventive vs Problem Visit

When a preventive visit includes a problem-oriented component, both can be billed with mod 25. Often missed.

Pediatric Coding

Age-specific preventive codes, vaccine schedules, and developmental screening codes require careful selection.

Multi-Reason Encounters

Patients present with multiple concerns. Capturing all billable diagnoses and services maximizes revenue.

Vaccine Administration

Administration codes (90471-90474) are separate from the vaccine product codes and frequently under-billed.

Common Family Practice Denial Reasons

We prevent these before submission and appeal aggressively when they occur.

!
Preventive visit billed without age-appropriate code
!
Modifier 25 missing on split preventive/problem visit
!
Vaccine administration code not billed separately
!
E/M level not supported by documentation
!
Screening code billed without qualifying diagnosis
!
Duplicate preventive visit within 12 months

Revenue Opportunities Most Family Practice Practices Miss

Family practice revenue optimization centers on capturing every billable service during multi-reason encounters. The average family practice visit generates 1.3 billable services, but with proper charge capture, that number should be 1.8 to 2.2. The biggest missed revenue area is the preventive + problem-oriented split visit. When a patient comes in for an annual physical and mentions knee pain, high blood pressure management, or a skin lesion, the problem-oriented portion is separately billable with modifier 25. Studies show that 30% to 40% of preventive visits include a problem-oriented component, but fewer than half of those are billed separately. For a practice performing 15 preventive visits per week, this can add $30,000 to $60,000 in annual revenue. Vaccine administration is the second largest missed charge. Every injection should generate two charges: the product code and the administration code. For a practice administering 50 vaccines per week, the administration codes alone (90471/90472 at $25 to $35 each) add $60,000+ annually. VFC (Vaccines for Children) program vaccines still generate administration charges even though the product is free. Care management codes (CCM, TCM, AWV) represent the same opportunity in family practice as in internal medicine. The Medicare patient panel in a typical family practice is smaller than internal medicine, but the codes are equally applicable.

Payer-Specific Family Practice Billing Tips

Family practice deals with the broadest payer mix of any specialty — Medicare, Medicaid, commercial, CHIP, VFC, workers comp, and self-pay all in the same-day. Each payer has different preventive care coverage rules. Medicare covers the annual wellness visit (G0438/G0439) at 100% with no deductible, but does NOT cover a routine physical exam. The AWV has a specific structure: health risk assessment, personalized prevention plan, and cognitive assessment. If your documentation looks like a traditional physical exam, the claim may be denied or recouped. Medicaid preventive care coverage varies by state but generally follows the Bright Futures schedule for pediatric visits and USPSTF recommendations for adults. Medicaid managed care plans often require referral authorization for specialist visits, and the referring family practice provider needs to submit the referral correctly to avoid denials for the specialist. Commercial payers under the ACA are required to cover preventive services without cost-sharing, but only when coded with the correct preventive diagnosis codes (Z00.xx series). If a preventive visit is coded with a disease diagnosis as primary, the patient's deductible and copay apply, leading to billing disputes and patient complaints.

Family Practice Billing Best Practices

Practical tips from our coding team to maximize reimbursement and minimize denials.

1
When a preventive visit includes a problem-oriented component (patient mentions a new symptom or chronic condition needs attention), bill both the preventive code and the E/M code with modifier 25.
2
Always bill vaccine administration codes (90471 for first injection, 90472 for each additional) separately from the vaccine product code. This is the most commonly missed charge in family practice.
3
For Medicare patients, annual wellness visits (G0438 initial, G0439 subsequent) are different from the Welcome to Medicare visit (G0402). Don't confuse them — each has different requirements.
4
Capture developmental screening codes for pediatric visits: 96110 (developmental screening, ~$10), 96127 (brief emotional/behavioral assessment, ~$5). These add up across your pediatric panel.
5
When performing office procedures (skin biopsy, cryotherapy, cerumen removal, joint injection), always document the procedure note separately from the E/M note to support billing both.

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What We Handle for Family Practice Practices

Full spectrum E/M coding (newborn to geriatric)
Preventive visit optimization with mod 25 capture
Immunization billing (admin + product codes)
Chronic care management (CCM) billing
Office procedure coding (biopsies, cryotherapy, injections)
Pediatric developmental screening codes
Medicare annual wellness visit coding
Multi-provider family practice billing

Why Choose Go Medical Billing for Family Practice

Family practice generates revenue across hundreds of CPT codes. Our coders capture every billable service during multi-reason encounters, preventive and problem visits are correctly split, and vaccine administration is never left unbilled.

We serve family practice practices in all 50 states, starting at 2.49% of collections. Our credentialing team handles payer enrollment, and our A/R specialists recover aging claims.

Family Practice Billing by State

We handle family practice billing in all 50 states. The 2026 Medicare allowables for family practice CPT codes in every state are in the fee table above. Open any state below for its full payer environment, Medicaid rules, and Medicare MAC policies.

CaliforniaTexasFloridaNew YorkPennsylvaniaIllinoisOhioGeorgiaNorth CarolinaMichiganNew JerseyVirginiaMassachusettsArizonaTennesseeMarylandIndianaMissouriWisconsinColorado
View all 50 states

Related Resources

Medical Billing & Coding ServicesA/R Recovery ServicesCredentialing & ContractingCase Studies & ResultsPricing

Frequently Asked Questions

When both occur in the same encounter, we bill both with modifier 25 on the E/M. This is commonly missed and can add $50-$100 per encounter.
Yes. Our team codes across the full age spectrum with age-appropriate preventive codes and vaccine schedules.
Yes. We bill both the administration codes and product codes for every immunization, including VFC program compliance.

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Stop losing revenue to family practice coding errors and preventable denials. Call 888-701-6090 for a free billing assessment.

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