Billing for family medicine, internal medicine, pediatric and NP-led primary care practices, from wellness visits to chronic care management.
Primary care is paid in small amounts at high volume, so one missed modifier or unlogged care management minute repeats across thousands of claims. A 99214 bundled into an annual wellness visit loses $135.61 at the 2026 Medicare rate, and eligibility and coverage errors caused 24% of denials in the Luxen claim audit. Our full-service medical billing team works inside your EHR under a signed BAA and fixes those claims before they go out.
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Primary care billing services manage coding, claims, denials and patient balances for family medicine, internal medicine and pediatric practices, including annual wellness visits, chronic care management, transitional care and the G2211 add-on. In Luxen billing reviews, primary care practices carried a median 36 days in AR, and chronic care management time went uncaptured for 58% of eligible patients.
Primary care billing looks routine until you count the code families: office visits, preventive exams, care management, vaccines and small procedures, often for the same patient in the same month. Each practice type loses money in a different place.
Family medicine sees every age, so one schedule mixes Medicaid well-child visits, commercial preventive exams and Medicare annual wellness visits, each with its own frequency and cost-sharing rule.
Medicare-heavy panels earn a large share of revenue from annual wellness visits, chronic care management, transitional care after discharge and advance care planning. Documentation timing decides whether those codes pay.
Pediatric practices bill vaccine products and administration together on nearly every well visit. NP-led clinics need rendering provider and incident-to rules applied claim by claim.
Most primary care leakage is not a denial. It is work performed and never billed, or billed at the wrong level. Dollar figures are 2026 national Medicare Physician Fee Schedule amounts, non-facility, from CMS fee schedule data, except 90480 from CMS vaccine pricing.
| Scenario | Codes | What goes wrong | $ at stake per claim | Luxen audit finding |
|---|---|---|---|---|
| Annual wellness visit where a problem is also treated | G0439 + 99214-25 | Modifier 25 missing, so the problem visit is bundled or denied | $135.61 | Problem-oriented visits billed with an annual wellness visit lacked modifier 25 on 12% of claims |
| Follow-up for an ongoing condition | 99213 + G2211 | Complexity add-on left off | $17.37 | G2211 was left off 31% of eligible Medicare follow-up visits |
| Monthly care for patients with two or more chronic conditions | 99490, 99439 | Staff minutes not logged or consent not documented | $66.13 per patient per month | Chronic care management time went uncaptured for 58% of eligible patients |
| Follow-up after hospital discharge | 99495, 99496 | No contact within 2 business days, so the visit is billed as a 99214 | $84.50 on 99495; $162.99 on 99496 | 24% of TCM-eligible discharge follow-ups were billed as routine office visits |
| COVID-19 vaccine given at a Medicare visit | Vaccine product code + 90480 | Administration code left off | $44.95 per dose | Vaccine administration codes were missing alongside vaccine product codes on 5% of claims |
These codes drive most primary care revenue. Amounts are 2026 national non-facility rates at the $33.4009 conversion factor from CMS fee schedule data. Your locality and commercial contracts will differ.
The level of an office visit is chosen by medical decision making (MDM) or by total time on the date of the encounter (AMA E/M guidelines). A visit that meets moderate MDM supports 99214 even when it took 20 minutes.
| Code | Visit | Time threshold | 2026 rate |
|---|---|---|---|
| 99212 | Established patient | 10 minutes | $59.45 |
| 99213 | Established patient | 20 minutes | $95.19 |
| 99214 | Established patient | 30 minutes | $135.61 |
| 99215 | Established patient | 40 minutes | $192.39 |
| 99203 | New patient | 30 minutes | $117.57 |
| 99204 | New patient | 45 minutes | $177.36 |
| G2211 | Add-on for an ongoing care relationship | Not time based | $17.37 |
| Code | Service | Key rule | 2026 rate |
|---|---|---|---|
| G0402 | Initial preventive physical exam (IPPE) | Once, within 12 months of Part B coverage | $174.69 |
| G0438 | Initial annual wellness visit | Once per lifetime | $174.35 |
| G0439 | Subsequent annual wellness visit | 11 full months after the last one | $137.61 |
| 99497 | Advance care planning | No cost sharing with the AWV, modifier 33 | $86.84 |
| G0444 | Depression screening | Not with G0438 or G0402 | $18.70 |
| 99490 / 99439 | CCM, clinical staff | First 20 minutes / each additional 20 | $66.13 / $50.44 |
| 99491 | CCM, physician or QHP | First 30 minutes | $89.18 |
| 99487 | Complex CCM | First 60 minutes, clinical staff | $144.29 |
| G0556 / G0557 / G0558 | APCM | Zero to one conditions / two or more / QMB with two or more | $16.37 / $53.78 / $117.24 |
| 99495 | TCM, moderate MDM | Visit within 14 days | $220.11 |
| 99496 | TCM, high MDM | Visit within 7 days | $298.60 |
Rules: Noridian AWV and IPPE, Noridian depression screening, CMS MLN909188 and CMS MLN908628. Our certified coders check each claim against them before submission.
A wellness visit and a sick visit on the same day is the most common primary care billing question, and Medicare and commercial plans answer it differently.
Medicare excludes routine physical checkups by statute (42 U.S.C. 1395y), so 99381 to 99397 do not pay. Medicare covers the IPPE (G0402) once within the first 12 months of Part B, then the initial AWV (G0438) once and the subsequent AWV (G0439) after 11 full months, with the deductible and coinsurance waived (Noridian).
When the clinician also treats a problem, bill 99202 to 99205 or 99211 to 99215 with modifier 25 (CMS). The patient owes cost sharing on that visit, which is why the bill surprises them. Since January 1, 2025, G2211 also pays on that modifier 25 visit when the same-day service is an AWV, vaccine administration or a Part B preventive service (MLN006764).
Non-grandfathered plans cover recommended preventive care in network without cost sharing, but a plan may charge cost sharing for an office visit billed separately from the preventive service (29 CFR 2590.715-2713). In June 2025 the Supreme Court upheld the Task Force structure behind those recommendations in Kennedy v. Braidwood Management (opinion).
In Minnesota, plans issued or renewed from January 1, 2026 cannot require prior authorization for USPSTF A or B services or ACIP-recommended immunizations (Minn. Stat. 62M.07). See our Minnesota medical billing page.
1 in 9 patient balance calls was about a preventive visit billed with a cost share (Luxen client data). Our patient billing team explains the split before the statement goes out.
Care management is monthly revenue that exists only when time, consent and dates are documented. Miss one element and a paid service becomes unbilled work.
Patient cost sharing applies (CMS MLN909188). CCM can be billed during the 30-day TCM period, but the same minutes cannot count toward both, and CCM and PCM cannot be billed by the same practitioner for the same patient in the same month (CMS CCM FAQs).
Advanced primary care management (G0556 to G0558) started January 1, 2025 with no time thresholds. The billing practitioner must be responsible for the patient's primary care, offer 24/7 access and document consent, and no initiating visit is needed if the practice saw the patient within 3 years (CMS APCM). For a patient with two chronic conditions, G0557 pays $53.78 a month without counting minutes, against $66.13 for a documented 20-minute 99490 month. APCM draws on elements of CCM, PCM and TCM, so check the concurrent billing limits in the CY 2025 final rule before moving a panel.
The 30-day TCM period begins on the discharge date. 99495 needs contact within 2 business days, moderate MDM and a visit within 14 calendar days. 99496 needs high MDM and a visit within 7 days. Only one practitioner may report TCM (CMS MLN908628).
Delaware requires group plans to pay chronic care management at no less than Medicare and bars patient deductibles and copayments on it (18 Del. C. 3556A). See our Delaware medical billing page.
The rule: since January 1, 2025, Medicare pays G2211 with a modifier 25 office visit when the same-day service is an AWV, vaccine administration or a Part B preventive service (MLN006764). Dropping it costs $17.37 per visit. G2211 was left off 31% of eligible Medicare follow-up visits in the Luxen claim audit.
The rule: the statute excludes routine physical checkups (42 U.S.C. 1395y). A 99397 sent to Medicare is denied, while a G0439 subsequent AWV pays $137.61 with no patient cost sharing. Coding and modifier errors caused 21% of denials in the Luxen claim audit.
The rule: CMS allows 99487, 99489, 99490 and 99491 during the 30-day TCM period, as long as minutes are not counted twice (CMS MLN909188). Skipping it costs $66.13 per patient per month on 99490. Chronic care management time went uncaptured for 58% of eligible patients in Luxen billing reviews.
The rule: you may submit the claim once the face-to-face visit is furnished and do not need to hold it until the period ends (CMS TCM FAQs). Holding a $298.60 99496 claim adds weeks to AR for nothing. At Luxen clients, median days in AR dropped from 54 to 33 within 120 days.
The rule: Medicare claims must be filed within 1 calendar year after the date of service (42 CFR 424.44). A corrected 99214 that misses the window loses the full $135.61. In Luxen billing reviews, 19% of denied claims were never reworked or appealed, which is why our denials and AR recovery team works by deadline.
We run the revenue cycle from eligibility to zero balance inside the practice management system you already use. How full-service billing works.
Certified coders review charges against your documentation and payer rules before the claim goes out, so the denial is prevented rather than appealed. Medical coding.
Aged and denied claims are worked to resolution, then the upstream cause is fixed so the same claims stop coming back. Denials and AR recovery.
Benefits are verified and authorizations secured before the appointment, which is the cheapest place in the cycle to stop a denial. Eligibility and prior authorization.
Statements, balance questions and payment plans are handled by the same team that worked the claim. Patient billing.
Payer enrollment and re-credentialing are tracked through to approval, so a lapsed credential never quietly stops payment. Credentialing.
A HIPAA-trained front-office assistant working inside your EHR on calls, scheduling, intake and referrals, alongside the billing team. Medical virtual assistant.
Primary care runs on EHRs built for high visit volume and care management tracking. We work inside athenaOne, eClinicalWorks, NextGen, Epic, Oracle Health, Elation Health, AdvancedMD, Tebra, Practice Fusion, Greenway Intergy and Veradigm, plus the payer portals and clearinghouse your practice already uses.
There is no migration. We sign a BAA before we touch a chart and bill from your system, so AWV templates, CCM time logs and vaccine records stay where your clinicians enter them. In the Luxen Practice Manager Survey 2026, 38% of practice managers had changed EHR or practice management system in the past five years, and of those, 71% said collections dipped for at least six months after the switch.
2 weeks
from a signed BAA to our team working your claims
About 3 weeks
to the first recovered payments on aged AR
20+ years
combined billing and coding experience
Coverage problems were usually discovered after the patient left. Luxen moved eligibility and benefit checks ahead of the appointment, reducing eligibility-related write-offs from $13,200 per month to $3,700.
Practice Administrator, multi-location primary care group
Our reports showed total collections but did not reveal which providers or payers were driving the backlog. Luxen built a weekly scorecard that helped us reduce AR over 90 days by $96,400 in one quarter.
Managing Partner, independent primary care practice
Full engagements are written up in our dental practice case study and our ambulance billing case study.
Our eligibility and benefits checks flag deductible balances before the visit.
Before you outsource, pull these numbers for the last 12 months. They show where a billing partner can recover money and give you a baseline to hold them to.
| KPI | Luxen benchmark | Luxen dataset |
|---|---|---|
| Days in AR | Primary care practices carried a median 36 days in AR | Luxen billing reviews |
| AR past 90 days | 27% of total AR sat past 90 days in the average practice reviewed | Luxen billing reviews |
| First-pass denials | Across 38 client practices, first-pass denial rate fell from 14.2% to 6.1% within 90 days of onboarding | Luxen client data |
| Clean claims | Clean claim rate rose from 89.6% to 97.3% in the first 90 days | Luxen client data |
| Underpayments | Underpayments against contracted rates appeared on 7.8% of paid claims | Luxen claim audit |
Check paid amounts against each contract's fee schedule, not against billed charges. The average underpaid claim was short by $38 (Luxen claim audit). Washington's Cascade Select public option may not set primary care reimbursement below 135% of Medicare (Washington HCA). See our Washington medical billing page.
Uninsured and self-pay patients must get a Good Faith Estimate when they schedule or ask, and they can dispute a bill that is at least $400 more than the estimate (45 CFR 149.610; 45 CFR 149.620). Plain-language statements plus text reminders raised patient collections 22% across 14 practices (Luxen client data).
3% to 6% of collections
Luxen's pricing generally falls between 3% and 6% of collections, depending on claim volume, specialty, payer mix, and how much of the revenue cycle your practice hands over.
Higher-volume practices usually land toward the lower end. Smaller or more complex practices land higher because there is more work per account. There is no setup fee and no exit fee, and the agreement runs month to month with 30 days notice.
A lower fee attached to weak billing is still expensive. The number that matters is what your collections do after you hire someone.
Luxen charges 3% to 6% of collections, month to month, with 30 days notice and no setup or exit fee. Where a practice lands depends on volume, payer mix and how much care management and AR cleanup it needs.
A group collecting $150,000 a month, or $1.8 million a year:
| Service line | Monthly collections | Luxen at 3% | Luxen at 6% |
|---|---|---|---|
| Office visits and G2211 | $105,000 | $3,150 | $6,300 |
| Wellness visits and preventive care | $18,000 | $540 | $1,080 |
| CCM, APCM and TCM | $15,000 | $450 | $900 |
| Vaccines and in-office procedures | $12,000 | $360 | $720 |
| Total | $150,000 | $4,500 | $9,000 |
| Cost | In-house | Luxen |
|---|---|---|
| Monthly | $11,850 at 7.9% of collections | $4,500 to $9,000 |
| Annual | $142,200 | $54,000 to $108,000 |
| When a biller leaves | Open biller roles took a median 67 days to fill (Luxen Practice Manager Survey 2026) | Coverage continues |
| Terms | Salaries, benefits, software and training | Month to month, 30 days notice |
Fully loaded in-house billing cost 7.9% of collections for practices under $2M, across 96 practices that shared payroll data (Luxen billing reviews).
Get the answers in writing. In the Luxen Practice Manager Survey 2026, 42% of practice managers said nobody owns denial follow-up full time, and 44% could not name the fee basis in their current billing contract.
| Option | Primary care coding depth | Denial follow-up | Cost basis | Watch for |
|---|---|---|---|---|
| In-house biller | Depends on one or two people | Often part time | 7.9% of collections under $2M | Gaps when staff leave |
| Generalist billing company | Broad, thin on care management | Queue based | Percent of collections | Missed AWV, CCM and G2211 revenue |
| Specialty billing company | Strong on codes | Varies | Percent of collections | Contract length and exit terms |
| EHR vendor RCM | Tied to the software | Varies by tier | Percent of collections plus software | Billing tied to one vendor |
| Luxen | Certified coders on primary care rules | Worked by reason and deadline | 3% to 6% of collections | Month to month, no setup fee |
To see how options differ where you practice, compare medical billing companies by state.
A 30-minute look at your AR ageing, denial reasons and payer mix. You leave knowing what is recoverable, what we would work first and what it would cost.
We sign a business associate agreement before anyone touches your system. Your named team then works inside the practice management system and clearinghouse you already use. Nothing is migrated, and claims are being worked within two weeks of the signed BAA.
Aged and denied claims come first because that is revenue you have already earned. Most practices see the first recovered payments inside three weeks.
Once the backlog is moving, we take over the agreed part of the daily cycle: eligibility, coding review, submission, posting, denials and patient balances.
You know who owns your claims. The team works inside the practice management system and EHR you already run, with no migration.
Claims are coded by certified coders against your documentation and payer rules. Automation handles the repetitive checks so people spend their time on the claims that need judgment.
We sign a business associate agreement before accessing protected health information, and access is limited to the named people on your account.
We look at your AR ageing, volume, payer mix and denial profile first, then tell you what we believe is recoverable and what it would cost.
A billing company is a poor fit if you are not willing to share visibility into your billing, if the vendor uses a rotating pool of people who never learn your practice, or if it cannot explain why your claims are being denied. Be wary of anyone promising large collection increases before they have seen your AR ageing. The right partner makes your revenue cycle more visible, not less.
A company that cannot report denials by reason, payer and provider every month. Ask how it captures modifier 25 on same-day wellness and problem visits and G2211 on follow-ups, the most common primary care misses. In the Luxen Practice Manager Survey 2026, 63% could not name their top three denial reasons.
Most outsourced billing is priced as a percentage of collections. Luxen charges 3% to 6% of collections, so a practice collecting $150,000 a month pays $4,500 to $9,000. Fully loaded in-house billing cost 7.9% of collections for practices under $2M in Luxen billing reviews.
About 2 weeks from a signed BAA to working claims. Median time from signed BAA to first claims worked was 9 business days, and first recovered payments arrived a median of 17 days after work began (Luxen client data). We work the oldest AR first, so claims near the 12-month Medicare filing limit are not lost in the handover.
Yes. We sign a BAA, then work inside your existing EHR and practice management system, including athenaOne, eClinicalWorks, NextGen, Epic and Elation Health, with no migration. Of practice managers who changed systems, 71% said collections dipped for at least six months after the switch (Luxen Practice Manager Survey 2026).
Yes. Bill G0439 for the subsequent AWV and the problem visit, such as 99214, with modifier 25. The AWV has no cost sharing, but the patient owes the usual cost sharing on the office visit, and since January 1, 2025 G2211 can be added to it. In the Luxen claim audit, problem-oriented visits billed with an annual wellness visit lacked modifier 25 on 12% of claims.
Thirty minutes, no deck and no fee. We look at what is sitting past 90 days and where your denials cluster, and you leave knowing what is recoverable, what we would work first, and what it would cost.
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