Family practice billing covers more ground than almost any other specialty, since one physician’s schedule can include a newborn check, a sports physical, a prenatal visit, a skin biopsy, and a Medicare wellness visit before lunch. Each of those patients brings a different payer and a different code set, often Medicaid or CHIP for the kids, commercial plans for working adults, and Medicare for older patients. What a family medicine practice actually collects depends on getting the age-specific rules right for every one of them.
Key Takeaways
- Preventive visits bill by age band and new or established status (99381 to 99387 and 99391 to 99397), and a problem treated at the same visit bills separately with modifier 25.
- Vaccines from the Vaccines for Children program are free to the practice, so only the administration fee is billed, under rules that vary by state Medicaid program.
- Vaccine counseling for patients 18 and younger bills as 90460 and 90461, while 90471 to 90474 apply when those counseling rules aren’t met or the patient is older.
- Medicare pays G2211 on a modifier 25 visit when the other same-day service is an annual wellness visit, a vaccine administration, or another Part B preventive service.
- Family physicians who deliver babies need obstetric privileges, obstetric malpractice coverage, and a plan for billing global maternity codes.
Preventive Visits Across Every Age
Preventive medicine codes are split by age and by whether the patient is new or established. A new patient under one year bills 99381, and the bands step up through 99387 for patients 65 and older, with the established codes running parallel from 99391 to 99397. A wrong age band is one of the quickest denials a family practice can get, and it happens most around birthdays.
Medicare doesn’t pay for routine physicals at all. Older patients on Medicare get the Initial Preventive Physical Exam in their first year of Part B and an annual wellness visit after that, which is a planning visit rather than a head-to-toe exam. Our geriatric medicine page covers the wellness visit and care management codes for that age group.
When a provider also treats a new or existing problem during a preventive visit, the problem bills as a separate E/M service with modifier 25. The documentation has to show that problem work went beyond what the preventive exam already includes, and the patient’s normal cost-sharing applies to that part. Sports and camp physicals are a separate question, since most plans don’t cover them and the patient pays at the time of service.
Well-Child Care, Screenings, and Vaccines
Pediatric preventive visits often carry several add-on services. Developmental screening with a standardized instrument bills as 96110, brief emotional or behavioral assessments such as depression screening bill as 96127, and vision and hearing screens have their own codes. Medicaid’s EPSDT benefit covers these screenings for patients under 21, and many state Medicaid programs require EPSDT referral indicators or specific condition codes on the claim.
Vaccine billing depends on the patient’s age and who paid for the vaccine. For patients 18 and younger, 90460 covers the first vaccine component when a physician or other qualified provider counsels the family, and 90461 covers each additional component. When those counseling rules aren’t met, or the patient is older, administration bills under 90471 to 90474. Vaccines from the Vaccines for Children program cost the practice nothing, so the practice bills only the administration fee, and each state Medicaid program sets its own rules for how the VFC vaccine code appears on the claim.
Medicare vaccines follow their own path. Flu, pneumococcal, hepatitis B, and COVID-19 vaccines are covered under Part B with HCPCS administration codes, while shingles, RSV, and Tdap vaccines for Medicare patients usually fall under Part D, so the practice has to bill the patient’s drug plan or send the patient to a pharmacy. Our pediatric billing page goes deeper on VFC and Medicaid managed care.
Chronic Care, Behavioral Health, and Add-On Codes
Family physicians manage most of their patients’ chronic conditions between visits, and much of that work is billable. Chronic care management, principal care management, and Advanced Primary Care Management (G0556 to G0558) each pay monthly, but the same clinician can’t bill APCM in the same month as CCM or transitional care management for that patient. Practices that treat depression and anxiety in house can add general behavioral health integration (99484) or the psychiatric collaborative care codes (99492 to 99494). Our behavioral health page covers practices that bill those services as their main line.
G2211 is the Medicare add-on for being a patient’s continuing source of care, and family medicine visits fit it better than almost any specialty. It can now be added to a modifier 25 E/M visit when the other same-day service is an annual wellness visit, a vaccine administration, or another Part B preventive service, and for 2026 it also applies to home visits. Our post on the G2211 add-on code covers when it doesn’t apply.
Medicare’s telehealth flexibilities for office visits now run through December 31, 2027, which keeps audio-video follow-ups and many behavioral health visits billable from the patient’s home. The details are in our post on the 2027 telehealth extension.
Office Procedures and Maternity Care
Office procedures pay well for family practices but carry their own coding rules. Skin biopsies bill by technique, with 11102 and 11103 for tangential biopsies, 11104 and 11105 for punch biopsies, and 11106 and 11107 for incisional biopsies. Joint injections bill as 20610, or 20611 when ultrasound guidance is used and documented. IUD insertion bills as 58300 and contraceptive implant insertion as 11981, with the device itself billed separately unless a payer supplies it. Most of these procedures carry a 0- or 10-day global period, so a follow-up for the same problem inside that window isn’t billed again.
Family physicians who deliver babies bill maternity care as a package. Global codes such as 59400 for a vaginal delivery and 59510 for a cesarean include routine prenatal visits, the delivery, and postpartum care, and the practice bills once after delivery. When a patient transfers in or out partway through the pregnancy, the practice bills only the portion it provided, using the antepartum or postpartum codes instead. Groups with a larger obstetric volume should compare notes with our OB/GYN billing page.
Family Medicine Credentialing
Physicians and board certification
Family physicians certify through the American Board of Family Medicine, which requires ongoing continuing certification rather than a single exam every ten years. Payers verify that certification, along with the state license, DEA registration, malpractice history, and any hospital privileges. Physicians who deliver babies, perform procedures under sedation, or round in nursing homes need privileges for each of those, and their malpractice policy has to name obstetric coverage if they deliver.
NPs, PAs, and incident-to billing
Nurse practitioners and physician assistants carry a large share of family practice visits, and each one needs their own NPI, Medicare enrollment, and credentialing with every commercial and Medicaid plan the practice accepts. Medicare pays their services at 85% of the physician fee schedule under their own NPI. Billing under the physician at 100% as incident-to services is allowed only for established patients on an existing physician plan of care, with a physician providing direct supervision, which Medicare now permanently allows through real-time audio and video.
Medicaid, CHIP, and the VFC program
Because family practices see children, most enroll with the state Medicaid program, each Medicaid managed care plan in their market, and the state CHIP plan. Each one credentials separately, and a provider can be active with traditional Medicaid while still pending with the managed care plans that cover most of the children. Enrollment in the Vaccines for Children program is a separate application through the state health department, and the practice can’t administer VFC vaccines until it’s approved. Our answer to whether you can bill while credentialing is in progress explains what happens to claims during that wait.
Family Practice Billing FAQ
Can a family physician bill a preventive visit and a sick visit on the same day?
Yes. The preventive visit bills under its age-based code, and the problem-oriented work bills as a separate E/M service with modifier 25. The note has to show problem work beyond what the preventive exam already covers.
How are Vaccines for Children vaccines billed?
The practice bills only the administration fee, because VFC supplies the vaccine at no cost. Each state Medicaid program sets its own rules for how the vaccine code appears on the claim, and the administration fee is capped at a regional maximum.
When do 90460 and 90461 apply instead of 90471?
For patients 18 and younger when a physician or other qualified provider counsels the patient or family about the vaccine. 90460 covers the first component of each vaccine and 90461 each additional component. Without that counseling, or for older patients, 90471 to 90474 apply.
Can G2211 be billed with a modifier 25 visit?
Yes, when the other same-day service is an annual wellness visit, a vaccine administration, or another Medicare Part B preventive service. It still isn’t payable with modifier 25 visits tied to procedures.
Does Medicare pay for routine physicals?
No. Routine physicals are excluded from Medicare coverage. Medicare patients get the Initial Preventive Physical Exam in their first year of Part B and an annual wellness visit each year after that.
Do NPs and PAs in a family practice need their own payer enrollment?
Yes. Each one needs an individual Medicare enrollment and separate credentialing with each commercial and Medicaid plan. Billing their visits under a physician as incident-to is allowed only when Medicare’s established-patient and supervision rules are met.
Medwave’s Support for Family Medicine Groups
Family practice revenue tends to leak at the edges, through a birthday that changes the age band, a VFC claim formatted the wrong way for the state, or a modifier 25 visit without the note to back it. Medwave checks each of those before the claim goes out, along with global periods on office procedures, and our medical billing team holds a 98% clean claim rate across the practices we work with.
Adding a provider to a family practice means Medicare, commercial plans, Medicaid managed care, CHIP, and often VFC, all at once. Our medical credentialing team files those together and averages 85 days to approval, and our payer contracting team reviews preventive and vaccine rates, which are often the most underpaid lines in a family medicine contract. Adult-focused practices can find related services on our primary care page.
Tell us how many providers you have and which payers you see most, and we’ll start with the claims that are costing you the most.