Primary care billing and revenue cycle management
Primary care RCM covers billing the full range of a family or internal medicine practice: choosing the right E/M level, billing preventive and problem visits together correctly, capturing care management programs like chronic and transitional care, and chasing denials. Medalyze handles those workflows so primary care practices collect what they've earned.
Where does primary care revenue go missing?
Primary care practices bill high volumes of similar visits, and small habits add up. A practice that leaves a level on the table for a fraction of its visits, or skips a billable program, feels it across a year.
- E/M leveling. Visits are coded on medical decision making or total time. Many practices default to the same level (often 99213 or 99214) regardless of what was documented, which under- or over-states the visit.
- Preventive plus problem visits. When a patient has a preventive exam and a separate problem addressed in the same visit, modifier 25 and careful documentation determine whether both can be paid. Payers scrutinize this combination.
- Add-on complexity code G2211. Medicare's visit complexity add-on applies in certain ongoing-care relationships, and its use with modifier 25 has changed over the last few years. See our post on the CY2027 PFS G2211 and modifier 25 changes.
- Annual wellness visits. Medicare's initial and subsequent annual wellness visits (G0438, G0439) differ from a routine physical, which Medicare doesn't cover, and patients need to know before they come in.
- Care management programs. Chronic care management (99490 and related codes), principal care management, transitional care management (99495, 99496) and remote monitoring can add meaningful revenue, but each has time, consent and documentation requirements that are easy to miss.
- Immunizations. Vaccine product codes and administration codes (such as 90471 or 90460) have to be billed together, with correct counseling and age rules.
- Value-based contracts and risk adjustment. For Medicare Advantage and similar contracts, accurate diagnosis capture and quality measure reporting affect payment well beyond the individual claim.
What does Medalyze do for primary care practices?
- Eligibility and benefits verification before visits, including preventive coverage and copay structure.
- E/M and charge review. We review documentation against the level billed, and flag patterns of under- or over-coding.
- Claim submission. Claims are checked for modifier 25, add-on codes, diagnosis linkage and payer-specific edits.
- Care management billing support. We help track qualifying time and consent for CCM, TCM and RPM so eligible services are billed correctly.
- Payment posting and underpayment checks. We compare payments to expected rates and flag variances.
- Denial management and AR follow-up. We work denials by cause and share the patterns with your front desk and providers.
- Reporting. E/M level distribution, denial rate, days in AR and collections by payer and provider.
Which codes and rules matter most?
| Area | Examples |
|---|---|
| Office visits | 99202 to 99205, 99212 to 99215 |
| Preventive | 99381 to 99397, G0438, G0439 |
| Add-ons and modifiers | G2211, modifier 25 |
| Care management | 99490, 99487 (chronic care), 99495, 99496 (transitional care) |
| Immunizations | Vaccine product codes with 90460 or 90471 administration |
| Rules that drive denials | Modifier 25 combinations, frequency limits on preventive services, missing consent or time documentation, diagnosis linkage |
Who is this for?
Independent family medicine, internal medicine and pediatric practices, and groups that want to start or grow care management programs without adding administrative staff.
Frequently asked questions
Can a preventive visit and a sick visit be billed on the same day?
Often yes, when a significant, separately identifiable problem is addressed beyond the preventive work, using modifier 25 on the problem visit and documentation that supports both. Payer policies differ, and some reduce payment, so we check each payer's rule.
What is G2211?
G2211 is a Medicare add-on code for the additional work involved in ongoing, longitudinal care for a patient's serious or complex condition. When it can be billed, especially alongside modifier 25, has been adjusted in recent payment rules.
What is the difference between a physical and an annual wellness visit?
A routine physical is a comprehensive head-to-toe exam that Medicare generally doesn't cover. An annual wellness visit is a Medicare benefit focused on a health risk assessment and a personalized prevention plan. Patients should know which they're booking and what they may owe.
Is chronic care management worth setting up?
It depends on the number of eligible patients and your ability to track time and consent. When those are in place it can be a steady revenue source. We can help you assess it using your own patient list.
Do you work with pediatric practices?
Yes, including immunization billing and preventive visit rules specific to children and Medicaid.
Related services: eligibility and benefits verification; medical coding services; claim creation and submission; payment posting; denial management; accounts receivable follow-up; practice analytics.
Related reading: CY2027 PFS G2211 and modifier 25 changes; CY2027 RPM/RTM direct employment requirement; why medical claim denials are rising.
Related specialties: rural health clinics and fqhcs.
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