Primary care billing

Primary care billing covers the everyday work of family medicine, internal medicine, and general pediatrics: office and outpatient evaluation and management (E/M) services, preventive and wellness visits, immunizations, and the coordination of care across a patient panel. Because these practices see a wide range of encounters at high volume, the revenue cycle depends on capturing the right visit type and level for each encounter rather than on a small set of high-value procedures. Pediatric practices share that shape but add rules that apply to nobody else -- age- and counseling-driven immunization administration coding, federally supplied Vaccines for Children stock that cannot be billed as a product, and a required EPSDT periodicity schedule -- and those rules are the subject of the separate pediatrics guide under Solutions rather than of this page.

What makes primary care distinct is the constant split between preventive and problem-oriented work. A wellness visit follows one set of coding rules and cost-sharing expectations, while an acute or chronic problem addressed in the same encounter follows another. Documentation has to make clear what was preventive, what was problem-oriented, and why any separately reportable work was medically necessary.

Primary care also carries a heavy eligibility and benefits burden. Preventive coverage, frequency limits, immunization benefits, and coordination of benefits vary by payer and plan, so a large share of the work happens before the visit. Longitudinal programs such as chronic care management add their own consent, care-plan, and time-tracking requirements on top of the visit-based workflow.

Family medicine and internal medicine bill under these same rules, and the difference between them is the panel rather than the code set. A family medicine practice sees the whole age range, so it runs two preventive regimes side by side -- childhood well visits against a periodicity schedule at one end, Medicare wellness visits at the other -- and the same clinician moves between them in a single session. An internal medicine practice is adult-only and therefore Medicare-weighted, which concentrates its preventive volume in a pair of Medicare-specific visits with an eligibility rule that catches practices out.

That rule is worth stating precisely, because it is a sequencing rule rather than a coding one. Under 42 CFR 410.16, a beneficiary is eligible for the Initial Preventive Physical Examination only if it is furnished not more than one year after the effective date of their first Medicare Part B coverage -- it is a once-in-a-lifetime service inside a closing window. Under 42 CFR 410.15, a beneficiary becomes eligible for an Annual Wellness Visit only once they are no longer within twelve months of that same date and have not received either an IPPE or an AWV in the past twelve months. A new Medicare patient in month three is therefore eligible for one of these visits and not the other, and neither is a physical examination in the sense a patient means by the word.

Geriatric practice sits inside this page for the same reason, and the rules that do change for it are worth naming because they are so often mistaken for specialty rules. Nothing in Medicare's payment machinery keys on a geriatrics designation: the E/M families, the preventive services, the care-management programs and the payer logic are the ones described above. What changes is the place of service. Once a patient is a resident of a long-term care facility, 42 CFR 483.30 attaches conditions to their care that no office patient has -- the resident must be seen by a physician at least once every thirty days for the first ninety days after admission and at least once every sixty days thereafter, with a visit treated as timely if it occurs not later than ten days after it was due, and the physician must review the resident's total program of care, write and sign a progress note, and sign and date the orders at each of those visits.

The delegation rules are the part that most affects who may bill. 42 CFR 483.30(c)(3) requires all mandated physician visits to be made by the physician personally, with two exceptions the regulation states carefully: in a skilled nursing facility, at the physician's option, required visits after the initial visit may alternate between personal visits and visits by a physician assistant, nurse practitioner or clinical nurse specialist; and in a nursing facility, at the option of the State, any required physician task -- including tasks the regulations say must be performed personally -- may be satisfied by a non-employee nurse practitioner, clinical nurse specialist or physician assistant working in collaboration with a physician. So whether a required visit may be delegated depends on the facility type and, in one case, on the State. That is a condition attached to the facility and its residents, not to the physician's specialty, and it applies identically to an internist, a family physician and a geriatrician.