Specialties
Family Practice Billing Services
A family practice may see a newborn, a high school athlete and a Medicare patient before lunch, often with a small team and a mix of physicians, nurse practitioners and physician assistants. Billing has to switch rules patient by patient: preventive codes by age, Medicaid for one family and Medicare Advantage for the next, and in-office procedures that a pediatric or internal medicine office would refer out.
- Preventive coding that follows each patient's age and payer
- Office procedures and injections captured with their supplies and drugs
- NP and PA visits billed under the right provider and rules
Billing across every age group in one practice
The full preventive code family runs from infancy to 65 and over, with separate new and established codes for each age band, and family physicians use nearly all of it. Add Medicare's own wellness visits for seniors and Medicaid's rules for children, and the same schedule can require several different preventive billing rules in one session.
Family practices also do more procedures in-house than most primary care offices: joint injections and aspirations, skin biopsies and lesion removals, abscess drainage, trigger point injections and medication injections such as B12 or contraception. Each procedure needs its own code, any drug its HCPCS code and units, and the visit on the same day needs modifier 25 only when there was separate work.
Small teams feel billing complexity most. When one person handles registration, prior authorizations and claims, rules that depend on age, payer and which provider saw the patient are the ones that slip.
Family medicine claims that get stuck
Sports or school physicals billed to insurance
Plans often exclude forms-only or sports physicals, or cover only one preventive visit a year, which the sports physical may use up.
NP or PA visit billed under the physician without meeting incident-to rules
A new problem seen by a nurse practitioner billed under the physician's NPI, which Medicare incident-to rules do not allow.
Procedure drug left off the claim
A joint injection billed without the steroid, or an injection without the medication's units.
Preventive code for the wrong age
A patient who crossed an age band since their last visit billed with last year's code.
Medicare patient billed a routine physical
A routine physical code sent to Medicare instead of a wellness visit.
Family medicine procedure and visit codes
In-office services that family practices perform and bill most often, beyond office visits.
| Codes | Service | Billing notes |
|---|---|---|
| 20600, 20605, 20610 | Arthrocentesis, aspiration or injection of a small, intermediate or major joint, without ultrasound guidance. | Chosen by joint size; the drug injected is billed with its own J-code. |
| 96372 with a J-code | Therapeutic, prophylactic or diagnostic injection, subcutaneous or intramuscular, plus the drug. | Payer policies differ on billing it with a same-day visit, so we check each payer's rule. |
| 11200, 17110, 10060 | Removal of skin tags, destruction of benign lesions such as warts, and incision and drainage of an abscess. | Cosmetic removals are not covered; document symptoms for medical removal. |
| 20552, 20553 | Trigger point injections, by number of muscles. | Coded by the number of muscles injected; all injections into them are included. |
| 99381 to 99387, 99391 to 99397 | Preventive medicine visits for new and established patients, from infancy to 65 and over. | Chosen by the patient's age on the date of service; Medicare does not cover a routine physical, so Medicare patients use its own preventive visits. |
| 59400 and related obstetric codes | Global obstetric care, for family physicians who provide maternity care. | The maternity codes are being restructured; our OB/GYN billing page covers global and split billing and the change. |
CPT is a registered trademark of the American Medical Association.
Official sources: CMS: CMS-416 instructions (child preventive code bands) (external site), CMS NCCI Policy Manual, chapter 4 (joint injections) (external site), CMS Benefit Policy Manual, chapter 15 (incident-to) (external site), eCFR: 42 CFR 410.32 (direct supervision) (external site), CMS: Medicare wellness visits (external site), CMS Claims Processing Manual, chapter 12 (external site), CMS Claims Processing Manual, chapter 30 (external site), CMS NCCI Policy Manual, chapter 7 (external site), CMS: relative value file (external site), CMS coverage database: article A54602 (external site), CMS coverage database: article A54682 (external site), CMS coverage database: article A56766 (external site), CMS coverage database: article A57701 (external site)
Physicians, NPs and PAs under one roof
Many family practices rely on nurse practitioners and physician assistants. Under Medicare's incident-to rules, an NP or PA visit can be billed under the supervising physician only when it is part of a course of treatment the physician started and the physician provides direct supervision, which for some services can include real-time audio and video. A new problem has not been started by the physician, so that visit goes under the NP or PA's own NPI. Otherwise it is billed under the NP or PA's own NPI, which Medicare pays at a lower percentage of the fee schedule; we track the current rate.
Commercial plans set their own rules: some credential NPs and PAs individually, some require billing under the physician, and some pay the same as a physician. The rule for each payer is recorded once and applied to every claim.
Official source: CMS: Physician Fee Schedule (external site)
Our family practice billing routine
Step 1: Set rules by payer and age
Each patient's payer and age band decide the preventive codes and frequency checks applied to their visit.
Step 2: Match procedures to supplies and drugs
Procedure notes are checked for the drug, dose and supplies used, so nothing performed goes unbilled.
Step 3: Bill each provider correctly
Visits by NPs and PAs are billed under their own NPI unless incident-to or payer rules allow otherwise.
Step 4: Handle physicals and forms up front
Sports and school physicals are identified at scheduling, with the patient told whether insurance will pay.
Family practice, pediatrics and internal medicine: what differs
Family medicine overlaps with both. These are the billing differences that matter.
| Area | Family practice | Pediatrics and internal medicine |
|---|---|---|
| Patient ages | All ages, so every preventive age band and both child and senior programs. | Pediatrics: children only. Internal medicine: adults only. |
| Payer mix | Medicaid, commercial and Medicare in the same day. | Pediatrics leans on Medicaid and CHIP; internal medicine on Medicare and Medicare Advantage. |
| Procedures | Many in-office procedures and injections. | Usually fewer, with more referrals to specialists. |
| Distinctive work | Sports and school physicals, sometimes maternity and newborn care. | Pediatrics: vaccines and developmental screening. Internal medicine: care management and hospital follow-up. |
Our pediatrics and internal medicine billing pages cover those specialties' own rules in detail.
Frequently asked questions
Is a sports physical covered by insurance?
Often not as a separate service. Some plans cover it as the annual preventive visit, which can mean a later well visit is denied as too frequent. Many practices charge a flat self-pay fee for sports and school forms.
When can an NP's visit be billed under the physician?
For Medicare, only under incident-to rules: the visit is part of a course of treatment the physician started, under the physician's direct supervision. Otherwise it is billed under the NP's own NPI.
Do we bill the drug for a joint injection?
Yes, the drug is billed with its HCPCS code and units in addition to the injection procedure code, unless the payer bundles it.
We deliver babies. How should we bill maternity care?
Usually with a global obstetric code after delivery, or split codes if care was shared with another practice. Our OB/GYN billing page explains the global package in detail.
Can a small family practice outsource only part of its billing?
Yes. Many small practices keep registration and check-in in house and hand over claims, denials and A/R. MEDCLAIM offers that kind of partial engagement.
Related services and specialties
Related services
Medical Billing
Charge entry, claim scrubbing, submission, payment posting and follow-up handled by a dedicated billing team.
Learn more about Medical BillingInsurance Eligibility Verification
Coverage, benefits, coordination of benefits and patient cost share confirmed before the visit, so claims start with the right payer.
Learn more about Insurance Eligibility Verification
Specialties
Internal Medicine Billing
Adult chronic disease care: MDM-based E/M, chronic and principal care management, wellness visits, transitional care and risk adjustment documentation.
Learn more about Internal Medicine BillingPediatrics Billing
Age-banded well-child visits, vaccine administration and product coding, Vaccines for Children, EPSDT, screening codes and coverage for minors.
Learn more about Pediatrics BillingUrgent Care Billing
Walk-in E/M levels, procedures and supplies, in-house X-ray and lab, occupational medicine, S-codes and per-visit payer contracts.
Learn more about Urgent Care Billing
Running a busy family practice with a small team?
Call us to talk through your payer mix and in-office procedures, or start with a free billing audit.