By the time a four-year-old leaves a well-child visit with three vaccines, a hearing screen, and a prescription for the ear infection her mother mentioned on the way out, the claim needs a preventive visit code, a problem-oriented visit with modifier 25, vaccine product codes, administration codes that depend on whether the provider counseled the parent on each vaccine, and possibly a Vaccines for Children modifier, all on a claim that pays a few hundred dollars. Primary care billing is mostly volume and small rules, and the practices that get paid for what they do are the ones whose systems apply those rules on every visit.
Key Takeaways
- Pediatric vaccines with counseling bill as 90460 for the first component of each vaccine and 90461 for each additional component, through age 18.
- Vaccines supplied free through Vaccines for Children aren’t billed for the product, only the administration.
- Medicare covers flu, pneumococcal, COVID-19, and hepatitis B vaccines under Part B, while most other adult vaccines fall under Part D.
- FQHCs and rural health clinics bill encounter-based rates on institutional claims, not the physician fee schedule.
- Behavioral health integration and collaborative care codes pay primary care practices for managing depression and anxiety alongside a behavioral health specialist.
Well Visits and Sick Visits
Preventive visits bill under age-based codes, 99381 to 99387 for new patients and 99391 to 99397 for established patients. Most plans cover them without cost-sharing under the ACA. Screenings done at the visit, such as developmental screening (96110), depression screening, and vision or hearing tests, bill separately when the payer allows it.
When a significant problem is addressed at the same visit, it bills as a separate office E/M with modifier 25, and the patient’s usual cost-sharing applies to that part. Front desk staff should tell families that before checkout, since a surprise copay on a “free” physical generates more complaints than almost anything else in primary care. Our internal medicine page covers adult preventive and problem visits, G2211, and office E/M levels in more detail.
Vaccine Billing
Every vaccine claim has two parts, the vaccine product and its administration. For patients through age 18, when the physician or qualified provider counsels the family on a vaccine, administration bills as 90460 for the first component of each vaccine and 90461 for each additional component. A combination vaccine with three components bills one 90460 and two 90461. Without face-to-face counseling, or for adults, administration bills as 90471 for the first injection and 90472 for each additional one.
Vaccines supplied free through the Vaccines for Children program aren’t billed for the product. The practice bills the administration only, and many state Medicaid programs require a specific modifier or a zero-dollar product line, so each state’s rules need to be followed.
Medicare splits adult vaccines. Influenza, pneumococcal, COVID-19, and hepatitis B vaccines are covered under Part B, with their own administration codes. Most others, including shingles and Tdap, are covered under Part D, which practices can only bill through a pharmacy or a Part D billing arrangement.
Care Between Visits
Primary care practices manage chronic conditions between visits, and several code sets pay for that time. Chronic care management (99490 and 99439, or 99491 for physician time) covers patients with two or more chronic conditions, and Advanced Primary Care Management (G0556 to G0558) pays a monthly amount by complexity. Transitional care management (99495 and 99496) covers the 30 days after a hospital discharge. Remote blood pressure and glucose monitoring bill under the remote patient monitoring codes.
Behavioral health integration pays primary care for managing depression, anxiety, and substance use in the practice. General BHI bills as 99484 for at least 20 minutes a month of care management. The collaborative care model bills as 99492 for the first month and 99493 for later months, with 99494 for additional time, and requires a behavioral health care manager and a consulting psychiatrist. Practices with in-house therapists can see our behavioral health page.
Telehealth
Most commercial payers and Medicare now want telehealth visits billed with the regular E/M code, modifier 95, and a telehealth place of service, POS 02 when the patient isn’t at home and POS 10 when the patient is at home. Audio-only visits take modifier 93 where the payer covers them. The older GT modifier is now limited mainly to critical access hospital billing. Medicare’s rules for telehealth to patients at home have been extended repeatedly, so current status should be checked before scheduling Medicare telehealth visits.
FQHCs and Rural Health Clinics
Federally qualified health centers and rural health clinics don’t bill Medicare under the physician fee schedule. FQHCs bill Medicare under a prospective payment system per visit, using FQHC-specific G-codes on an institutional claim with the services provided listed below them. RHCs receive an all-inclusive rate per visit. Both generally pay one encounter per patient per day, with limited exceptions for a separate mental health visit or an illness that develops after the first visit.
Medicaid pays FQHCs and RHCs through its own prospective payment rates, and managed care plans are required to make up the difference through wraparound payments. Care management and behavioral health integration have their own billing rules in these settings, which CMS has changed in recent years.
Primary Care Credentialing
Physicians and PCP designation
Family physicians certify through the American Board of Family Medicine, pediatricians through the American Board of Pediatrics, and internists through the American Board of Internal Medicine. Payers verify board status, licensure, DEA registration, and malpractice history, usually through CAQH ProView, and our CAQH ProView form collects what we need to build or update a profile. Many commercial, Medicaid managed care, and Medicare Advantage plans assign members to a primary care provider, so each physician needs to be credentialed as a PCP, not just a participating specialist, to receive attributed patients.
NPs, PAs, and new providers
NPs and PAs carry a large share of primary care visits, and each needs their own enrollment with every plan the practice bills. Medicare pays their visits at 85% unless the incident-to requirements are met. A new provider who starts seeing patients before enrollment is approved generates visits the practice can’t bill, which is why you can’t bill what you can’t credential.
Vaccine programs and recredentialing
Practices that give pediatric vaccines also enroll in the Vaccines for Children program through their state, which has its own recertification and storage requirements. Most payers recredential every three years.
Primary Care Billing FAQs
What’s the difference between 90460 and 90471?
90460 is for patients through age 18 when the provider counsels the family on the vaccine, and it’s billed per vaccine with 90461 for each additional component. 90471 is for administration without that counseling, or for adults.
How are Vaccines for Children doses billed?
The practice bills only the administration, since the vaccine is supplied free. Many state Medicaid programs require a modifier or a zero-dollar product line.
Which vaccines does Medicare Part B cover?
Influenza, pneumococcal, COVID-19, and hepatitis B. Most other adult vaccines, including shingles, are covered under Part D.
Can a sick visit be billed at a well visit?
Yes, when a significant problem is addressed beyond the preventive service. The problem visit bills as an office E/M with modifier 25, and the patient’s usual cost-sharing applies.
Is the GT modifier still used for telehealth?
Rarely. Most payers want modifier 95 with POS 02 or 10. GT is now mainly used for critical access hospital billing.
How do FQHCs bill Medicare?
Under a prospective payment system per visit, using FQHC-specific G-codes on an institutional claim, generally one encounter per patient per day.
What Primary Care Practices Get from Medwave
Primary care revenue is a lot of small claims, and the extras decide whether a visit pays well. Medwave captures preventive visits, annual wellness visits, care management, and same-day sick visits with modifier 25 when they qualify, and checks frequency limits so they aren’t denied. Our billing team keeps primary care at a 98% clean claim rate.
Our credentialing team enrolls physicians, NPs, and PAs in about 85 days, and our payer contracting work covers value-based arrangements as well as fee-for-service rates. Denied claims go to our denial management team, and family medicine groups can find more on our family practice page.
Practices with a heavy Medicare Advantage mix should reach out below.