Family Medicine Billing Audit
Confirm your E/M levels, preventive visits and care-management codes are billed to what you document — no more, no less.
Family medicine revenue depends on high-volume, low-dollar claims, so small coding errors repeat thousands of times a year. Since the 2021 office E/M changes, levels 99202–99215 are chosen by medical decision making or total time on the date of service, yet many practices still code from habit, leaving established-patient visits clustered at 99213 or, less often, billed higher than the note supports. Medicare's G2211 add-on for ongoing, longitudinal care and the rules for billing a preventive visit and a problem-oriented visit on the same day with modifier 25 add further room for error. Our audit codes a random sample of notes blind and compares the result with what was billed, then reviews your E/M distribution, preventive and Annual Wellness Visit billing, and care-management programs such as CCM and TCM.
Audit red flags
- Established-patient visits concentrated at 99213 even for patients managed for several chronic conditions.
- G2211 appended to every Medicare visit, including one-off acute problems and procedure visits billed with modifier 25.
- Preventive and problem visits billed on the same day without separate documentation of the problem-oriented work.
- CCM billed without documented patient consent, a care plan, or a time log that reaches the 20-minute threshold.
Audit action plan
- 1. Blind Chart Sample — Code a random sample of visits for each clinician without seeing the claim, then compare our levels with what was billed to measure under- and over-coding.
- 2. E/M Distribution Review — Compare each clinician's 99212–99215 distribution with specialty norms and their own documentation to find outliers worth a closer look.
- 3. Program Billing Check — Review AWV, CCM, TCM, advance care planning and vaccine administration billing for missing requirements and missed billable services.
Codes reviewed
- 99213 / 99214 — Established patient office visits (level 3 vs. level 4)
- G2211 — Visit complexity add-on for longitudinal care (Medicare)
- 99381–99397 + E/M-25 — Preventive visit with a separately identifiable problem-oriented visit
- 99490 / 99439 — Chronic care management by clinical staff, first 20 minutes / each additional 20 minutes
Frequently asked questions
Can we bill a preventive visit and a sick visit on the same day?
Yes, when a significant problem is addressed that needs work beyond the preventive service. Bill the preventive code and the problem-oriented E/M with modifier 25, and keep the problem work clearly separated in the note. Many commercial plans apply cost-sharing to the problem visit, so tell patients in advance.
When can G2211 be billed?
G2211 is a Medicare add-on to office and outpatient E/M visits when the practitioner is the continuing focal point for the patient's care or provides ongoing care for a serious or complex condition. It is generally not payable when the E/M carries modifier 25, except when the E/M is billed with an Annual Wellness Visit, vaccine administration or a Part B preventive service.
Does choosing E/M levels by time help family physicians?
It can for visits with extensive counseling, care coordination or record review on the same day. Total time counts both face-to-face and non-face-to-face work by the billing practitioner on the date of service, and it must be documented in the note.