Specialties
Internal Medicine Billing Services
Internal medicine is adult medicine for patients with several conditions at once. Much of the revenue sits outside the office visit: monthly care management, annual wellness visits, transitional care after a hospital stay, hospital and nursing facility rounds, and for Medicare Advantage patients, documentation that supports risk adjustment.
- Office visits leveled on medical decision making for complex adults
- Chronic and principal care management time tracked every month
- Wellness visits, physicals and transitional care kept distinct
Billing for adults with several chronic conditions
For an internist, the hard part of E/M is not the code range but the leveling. Office visits are leveled on medical decision making or total time, and the CPT guidelines judge decision making by the problems addressed, the data reviewed and the risk of management. A visit that manages diabetes, heart failure and a medication change is usually moderate or high complexity, but only if the note shows each problem was actually addressed.
Between visits, chronic care management pays for the non-face-to-face work of coordinating care for patients with two or more serious chronic conditions, and principal care management covers patients with one high-risk condition. Both need the patient's consent, a care plan and monthly time tracked to the minute.
Internists also follow patients across settings. Hospital, observation and nursing facility visits use their own code families, and the first visit after discharge may qualify as transitional care management if the practice contacts the patient within two business days and sees them within the required window.
Official source: CMS: Care Management (external site)
Annual wellness visit, initial preventive exam or physical?
Three visits that patients call a physical, each billed differently.
| Visit | Who it is for | What it includes |
|---|---|---|
| Initial preventive physical exam (G0402) | New Medicare Part B enrollees within their first 12 months. | A one-time review of history, risk factors and screenings, with limited exam elements. |
| Annual wellness visit (G0438, G0439) | Medicare patients after the first year, once every 12 months. | A health risk assessment and personalized prevention plan, not a full physical exam. |
| Preventive medicine visit (99385 to 99397) | Commercially insured adults, and Medicare patients paying privately. | An age-banded comprehensive preventive exam; not covered by Medicare. |
With the IPPE or annual wellness visit, a separately identifiable problem visit is billed with modifier 25. With a commercial preventive visit, the payer's own rules apply.
How we keep internal medicine claims accurate
Step 1: Build the care management roster
Eligible patients, their consent date and monthly minutes are tracked, so each month's claim reflects work actually done.
Step 2: Watch discharges
Hospital discharge notices trigger the two-business-day contact and the TCM visit window.
Step 3: Schedule the right preventive visit
Medicare patients are booked for the wellness visit or initial preventive exam they qualify for, not a routine physical.
Step 4: Review MDM on complex visits
Higher-level visits are checked for problems addressed, data and risk before release.
Step 5: Track facility rounds
Hospital and nursing facility visits are captured daily so rounding work is not lost.
Internal medicine E/M and care management codes
Codes internists bill beyond routine office visits. Medicare's rules are shown; commercial plans vary.
| Codes | Service | Requirements to note |
|---|---|---|
| 99490, 99439 | Chronic care management by clinical staff, first 20 minutes and each additional 20 minutes in the month. | At least two chronic conditions likely to last 12 months or more, consent and a care plan. |
| 99491, 99437 | Chronic care management personally performed by the physician or qualified provider, first 30 minutes and each additional 30. | Time must be the provider's own. |
| 99424 to 99427 | Principal care management for a single high-risk condition, by the provider or by clinical staff. | Usually for a condition that needs frequent adjustment or recent hospitalization. |
| 99495, 99496 | Transitional care management, moderate and high complexity. | Contact within two business days of discharge, then a visit within 14 or 7 days. |
| 99221 to 99239 | Hospital and observation care: initial, subsequent, and discharge day management. | Initial and subsequent codes are leveled on MDM or time. |
| 99304 to 99316 | Nursing facility initial, subsequent and discharge visits. | Federal rules on who makes required physician visits differ between skilled nursing and other nursing facilities, so we check them before NP visits are billed. |
| 99417, G2212 | Prolonged service beyond the highest-level visit time: CPT code and Medicare code. | Medicare uses G2212 with its own time threshold instead of 99417. |
| G2211 | Medicare add-on for visits where the practitioner is the continuing focal point for all needed care, or gives ongoing care for a serious or complex condition. | Not added when the visit is billed with modifier 25, except with the annual wellness visit, vaccine administration or another Part B preventive service. |
CPT is a registered trademark of the American Medical Association.
Official sources: CMS MLN: Chronic care management services (external site), CMS MLN: Transitional care management services (external site), CMS MLN: Evaluation and management services guide (external site), CMS Claims Processing Manual, chapter 12 (G2211) (external site), CMS: Medicare wellness visits (external site), CMS: annual wellness visit (external site), CMS: initial preventive physical exam (external site)
Denials in adult primary care
A routine physical billed to Medicare
Medicare does not cover a routine head-to-toe physical; it covers the wellness visit and the initial preventive exam instead.
Care management without consent or time
Monthly CCM or PCM claims with no documented consent or with minutes that do not reach the threshold.
TCM billed without the two-day contact
The discharge follow-up visit happened, but the interactive contact within two business days was never documented.
Two practices billing the same month of care management
Only one practitioner can bill CCM for a patient in a calendar month, so a specialist's claim can block yours.
MDM level not supported
High-complexity visits where the note lists conditions but does not show each was assessed or treated.
Risk adjustment documentation for Medicare Advantage
Medicare Advantage plans are paid partly on the documented health status of their members, so chronic conditions such as diabetes with complications, heart failure or chronic kidney disease need to be documented and coded from visits where they were actually addressed. Conditions mentioned only in a problem list, without evidence they were assessed, generally do not support risk adjustment.
A common internal convention is that each condition should show it was monitored, evaluated, assessed or treated at the visit. We review documentation for that support and code to the specificity the provider documented, never adding conditions the note does not support.
Frequently asked questions
Can we bill chronic care management and an office visit in the same month?
Yes. CCM covers the non-face-to-face work between visits, so office visits in the same month are billed separately, as long as the same time is not counted twice.
What makes a discharge follow-up qualify as transitional care management?
An interactive contact with the patient or caregiver within two business days of discharge, medical decision making of at least moderate complexity, and a face-to-face visit within 14 days, or within 7 days for high complexity.
Does Medicare cover an annual physical?
Not a routine physical exam. Medicare covers the initial preventive physical exam in the first year and an annual wellness visit after that, which focus on prevention planning rather than a full exam.
How do we document chronic conditions for risk adjustment?
Address each condition in the note with evidence it was monitored, evaluated, assessed or treated, and code it to the specificity documented.
When do prolonged service codes apply?
When total time on the date of the visit goes beyond the time for the highest-level visit by the threshold the payer uses. Medicare uses G2212, and other payers may use 99417.
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