RCM Xpert provides family medicine billing services for family practices and family medicine groups in all 50 states, from Flushing, New York.
Family practice medical billing services built for practices that see a newborn, a teenager and a Medicare patient in the same morning, with each visit coded to its age, payer and documentation, then followed until paid.
HIPAA protected. No obligation.
Family medicine billing is the coding, claim submission and payment follow-up for family physicians who treat patients of every age, where one practice bills well-child visits, vaccines, adult and Medicare preventive care, chronic disease visits and in-office procedures to Medicaid, CHIP, Medicare and commercial plans.
One family practice schedule can hold a two-month well-baby visit with three vaccines, a sick visit for a teenager, a diabetes follow-up and a Medicare Annual Wellness Visit. Each uses a different preventive code, vaccine rule and often a different payer. That is where general billing teams lose money: wrong age bands, Vaccines for Children claims billed like privately bought stock, and sick visits lost inside checkups.
RCM Xpert codes every family practice visit to the patient's age, payer and documentation, so a well-child visit, a sick visit and a vaccine given on the same day each reach the payer correctly.
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Family practice claims are usually denied for seven reasons: same-day sick and well visits billed without the right modifier, vaccine administration errors, preventive codes for the wrong age or frequency, procedures billed inside a global period, unsupported E/M levels, coverage changes for children and family plans, and tests without medical necessity.
When a patient comes in for a preventive visit and the physician also treats a significant new or worsening problem, both services can be billed. The problem-oriented E/M needs modifier 25 and documentation that stands apart from the preventive exam. Minor issues handled during the checkup are part of the preventive visit. Our coders bill the second service only when the note supports it, which protects the practice from both lost revenue and recoupment.
Every vaccine claim needs two lines: the vaccine product and its administration. For patients through age 18 whose physician counsels the family, administration is billed per vaccine component; for adults, or when no counseling is documented, it is billed per vaccine. Vaccines supplied through the Vaccines for Children program are free to the practice, so only the administration is paid. We match every vaccine line to its age, counseling, funding source and the payer's required format.
Preventive medicine codes are chosen by the patient's age on the date of service and whether the patient is new or established. A code from the wrong age band is denied, and so is a second preventive visit inside the payer's frequency limit. Medicare patients need an Annual Wellness Visit, not a routine physical, because Medicare does not cover routine physicals.
Skin lesion removals, abscess drainage and some injections carry a 10-day global period, and a follow-up visit inside it is not paid separately. A visit for an unrelated problem during the global period needs modifier 24, and an unrelated procedure needs modifier 79. We check the global period on every in-office procedure before billing the next visit.
Office E/M visits are coded from medical decision making or total time on the date of service under the 2021 AMA guidelines. Level 4 visits are common in family medicine because many adult patients manage two or more chronic conditions, and payers review those claims closely. We compare each higher-level visit with its documentation before submission.
Children move between Medicaid, CHIP and a parent's employer plan, and families switch plans at open enrollment. High-deductible family plans shift more of the bill to the patient. Real-time eligibility checks before every visit catch these changes before the claim is built.
In-office labs, ECGs and spirometry need a diagnosis the payer accepts for that test. When Medicare is likely to deny a test, a signed Advance Beneficiary Notice and modifier GA preserve the right to bill the patient, and CLIA-waived tests also need modifier QW.
Send us your recent family practice claims. We will show you your same-day visit pattern, your vaccine denials and the preventive visits that were billed under the wrong code.
Get My Free Billing AuditRCM Xpert provides family practice billing and coding services from the first eligibility check to the final payment, and practices can outsource the full cycle or only the steps their staff cannot keep up with.
Coverage checked before every visit, including Medicaid and CHIP changes for children, new family plans after open enrollment and high-deductible plan balances.
eligibility verification for family practices →Requests for imaging, specialty drugs and referrals sent with the clinical notes each payer asks for, then tracked to approval.
prior authorization →Visits, vaccines, screenings and procedures entered with the right age-based code, funding source and rendering provider.
family practice charge entry →Preventive, E/M, vaccine, procedure and diagnosis coding by certified coders who code from the note, not from the superbill.
medical coding services →Every claim checked against NCCI edits, age and frequency limits and payer rules before it is sent electronically on the 837P.
Each remittance posted and compared with the expected payment, so underpaid vaccine and preventive claims are caught and appealed.
payment posting →Denials worked by root cause and appealed with the documentation and payer policy needed to reverse them.
family practice denial management →Open claims followed by payer and age, so no balance passes a Medicaid or commercial filing limit.
A/R recovery →Clear family statements, payment plans for high-deductible balances and good faith estimates for uninsured and self-pay patients.
patient billing →Payer enrollment for physicians, nurse practitioners and physician assistants with Medicaid, CHIP plans, Medicare and commercial payers.
provider credentialing →Quality, cost and improvement activity reporting for Medicare's Merit-based Incentive Payment System, tracked against the 75-point threshold.
MIPS reporting →Preventive visits are billed with age-based codes, so a family practice uses a different code for a newborn, a school-age child, a teenager, an adult and a Medicare patient.
Commercial plans and Medicaid pay the preventive medicine codes, chosen by age on the date of service and by new or established status. Medicare pays the Initial Preventive Physical Exam once in the first 12 months of Part B coverage, then an Annual Wellness Visit once every 12 months with no patient cost sharing. The diagnosis on a preventive claim also follows age: Z00.129 or Z00.121 for a child's routine exam, and Z00.00 or Z00.01 for an adult's, depending on whether abnormal findings were documented.
| Patient age | New patient | Established patient | Payer rule |
|---|---|---|---|
| Under 1 year | 99381 | 99391 | Commercial and Medicaid; EPSDT for Medicaid |
| 1 to 4 years | 99382 | 99392 | Commercial and Medicaid; EPSDT for Medicaid |
| 5 to 11 years | 99383 | 99393 | Commercial and Medicaid; EPSDT for Medicaid |
| 12 to 17 years | 99384 | 99394 | Commercial and Medicaid; EPSDT for Medicaid |
| 18 to 39 years | 99385 | 99395 | Commercial and Medicaid; EPSDT for Medicaid patients 18 to 20 |
| 40 to 64 years | 99386 | 99396 | Commercial and Medicaid |
| 65 and older | 99387 | 99397 | Commercial plans only |
| Medicare, first year of Part B | G0402 (IPPE) | — | Once per lifetime |
| Medicare, yearly | G0438 (first AWV) | G0439 (later AWVs) | Once every 12 months; no cost sharing |
Vaccine billing in a family practice depends on two facts about each shot: the patient's age and who paid for the vaccine.
For patients through 18 years of age, when the physician or another qualified clinician counsels the patient or family, administration is billed with 90460 for the first component of each vaccine and 90461 for each additional component. A combination vaccine with several components earns more administration units than a single-component vaccine. Without documented counseling, the adult administration codes apply.
The Vaccines for Children (VFC) program supplies vaccines at no cost for eligible children, including those enrolled in Medicaid, uninsured or underinsured. Because the practice did not buy the vaccine, it bills only the administration. Many state Medicaid programs require the vaccine product line at zero charge or with modifier SL to show the vaccine was state-supplied, so the claim format follows each state's rule.
Adult administration uses 90471 and 90472 for injections and 90473 and 90474 for oral or nasal vaccines. Medicare Part B covers influenza, pneumococcal, hepatitis B and COVID-19 vaccines, with their own administration codes, while the shingles vaccine and most other adult vaccines fall under Part D. Diagnosis code Z23 goes on every vaccine claim.
| Situation | Administration codes | Rule |
|---|---|---|
| Age 18 or under, with counseling | 90460 · 90461 | First component of each vaccine · each additional component |
| Any age, injection, no counseling | 90471 · 90472 | First vaccine · each additional vaccine |
| Any age, oral or intranasal | 90473 · 90474 | First vaccine · each additional vaccine |
| Medicare Part B vaccines | G0008 · G0009 · G0010 | Influenza · pneumococcal · hepatitis B |
| VFC-supplied vaccine | Administration code only | Product line at zero or with modifier SL, per state Medicaid rules |
| Every vaccine claim | Z23 | Encounter for immunization |
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is the Medicaid benefit that covers preventive and follow-up care for enrolled children under age 21, and most well-child visits in a family practice are billed under it.
States build their EPSDT schedules on the American Academy of Pediatrics Bright Futures periodicity schedule, which sets the visits, screenings and tests due at each age. Screenings done at a well-child visit are usually billed in addition to the preventive code when the payer covers them, and some states require an EPSDT indicator or modifier on the claim. The Children's Health Insurance Program (CHIP) covers children in families that earn too much for Medicaid, with rules that vary by state.
| Screening | Code | When it is billed |
|---|---|---|
| Developmental screening | 96110 | Standardized instrument, scored and documented |
| Emotional or behavioral assessment | 96127 | Standardized instrument, such as depression screening for adolescents |
| Fluoride varnish | 99188 | Applied by the physician or a qualified clinician |
| Visual acuity screening | 99173 | Quantitative, both eyes |
| Hearing screening | 92551 | Pure tone, air only |
| Lead testing | 83655 with 36415 or 36416 | Lab test with venous or capillary collection |
We load each state's EPSDT schedule and claim rules into our edits, so screenings due at each age are billed and the claim carries whatever indicator that state requires.
Adult visits in a family practice are coded the same way as in internal medicine: by medical decision making or total time, with monthly care management codes paying for work between visits.
G2211, the Medicare add-on for visits where the practice is the continuing focal point of a patient's care, fits family medicine closely, because a family physician is often the one clinician who sees the whole household over time. Since 2025, G2211 can also be billed when the E/M carries modifier 25 with an Annual Wellness Visit, vaccine or Medicare Part B preventive service.
Family practices with Medicare panels also bill chronic care management for patients with two or more chronic conditions, principal care management for one complex condition, transitional care management after a hospital discharge, and advanced primary care management, which pays a monthly amount without time thresholds. For the full rules on these programs, see our internal medicine billing services.
| Service | Codes | Key rule |
|---|---|---|
| Office visit, new patient | 99202 to 99205 | Medical decision making or total time |
| Office visit, established patient | 99211 to 99215 | 99214: moderate MDM or at least 30 minutes; 99215: high MDM or at least 40 minutes |
| Medicare complexity add-on | G2211 | Continuing focal point or ongoing care for a serious condition |
| Chronic care management | 99490 · 99439 · 99491 · 99437 | Two or more chronic conditions; consent and care plan |
| Transitional care management | 99495 · 99496 | Contact in 2 business days; visit in 14 or 7 days |
| Advanced primary care management | G0556 · G0557 · G0558 | Monthly; not billed with CCM or TCM in the same month |
| Behavioral health integration | 99484 | Care for depression and anxiety within the practice |
Family physicians perform minor procedures in the office every day, and each one carries a global period that decides which follow-up visits are paid.
A procedure with a 0-day global period includes only same-day care, while a 10-day global period includes follow-up visits for the next 10 days. When the physician also evaluates a separate problem on the day of a minor procedure, the E/M needs modifier 25 and its own documentation. Drugs given during the procedure, such as a corticosteroid for a joint injection, are billed separately with their HCPCS code and units.
| Procedure | Code | Global period |
|---|---|---|
| Tangential skin biopsy, single lesion | 11102 | 0 days |
| Destruction of benign lesions such as warts, up to 14 | 17110 | 10 days |
| Incision and drainage of abscess, simple | 10060 | 10 days |
| Removal of skin tags, up to 15 | 11200 | 10 days |
| Simple wound repair, 2.5 cm or less | 12001 | 0 days |
| Arthrocentesis or injection, major joint | 20610 | 0 days |
| Removal of impacted earwax with instruments, one ear | 69210 | 0 days |
Our coders check the global period, modifiers and drug units on every procedure, so the procedure, the same-day visit and the follow-up are each billed only when they are payable.
Family physicians who provide prenatal care and deliver babies bill obstetric care as a global package, which covers routine prenatal visits, the delivery and postpartum care under one code.
A vaginal delivery with full prenatal and postpartum care is billed with 59400, and a cesarean delivery with 59510. When a patient transfers in or out during pregnancy, the practice bills only the care it provided: antepartum care alone with 59425 for four to six visits or 59426 for seven or more, and postpartum care alone with 59430. For practices with a dedicated women's health service, see our OB-GYN billing services.
OB-GYN billing services →Family medicine medical billing runs through more payer types than most specialties, because the patient panel spans every age and income level.
Children make up much of a family practice's Medicaid volume, and each state sets its own EPSDT rules, vaccine claim format and prior authorization list.
For 2026, the Medicare Physician Fee Schedule conversion factor is $33.4009, or $33.5675 for qualifying APM participants. E/M visits and care management codes were excluded from the 2.5% efficiency adjustment applied to many procedures and tests.
UnitedHealthcare, Aetna, Cigna, Blue Cross Blue Shield plans and Humana each set their own preventive frequency limits, modifier 25 policies and vaccine payment. High-deductible plans move more of every visit to the patient.
The No Surprises Act requires a good faith estimate of expected charges for uninsured and self-pay patients who schedule care in advance.
Medicare telehealth flexibilities, including visits with patients at home, are extended through 31 December 2027 under the Consolidated Appropriations Act, 2026.
Family practice billing must follow HIPAA, NCCI edits, payer coverage policies, Advance Beneficiary Notice rules, incident-to rules for nurse practitioners and physician assistants, and the False Claims Act. We check every claim against NCCI edits and the payer's policy before submission.
RCM Xpert works inside the EHR and practice management system your family practice already uses, so outsourcing billing does not mean changing software or retraining clinical staff.
Claims leave your system through your clearinghouse as 837P files, and electronic remittances (835 ERAs) post back into the same system, so your team sees every claim status in software it already knows. Well-child visits, vaccines and screenings are coded from the records your providers already keep, including each vaccine's funding source.
We work under a signed HIPAA Business Associate Agreement, with user accounts your practice creates for us and removes when the engagement ends.
RCM Xpert bills family practice claims in all 50 states, and each state changes three things: the Medicare Administrative Contractor, the Medicaid program and its managed care plans, and the name and rules of its EPSDT benefit for children.
Well-child visits for Medicaid children are billed under Texas Health Steps, and Novitas processes Medicare claims in Jurisdiction H.
Texas medical billing →Ohio's EPSDT benefit is called Healthchek, Medicaid managed care plans cover most children, and CGS processes Medicare claims in Jurisdiction 15.
Medi-Cal for Kids and Teens is California's EPSDT benefit, and Noridian processes Medicare claims in Jurisdiction E.
California medical billing →Florida bills child preventive care as the Child Health Check-Up, and First Coast processes Medicare claims in Jurisdiction N.
Florida medical billing →The Child/Teen Health Program is New York's EPSDT benefit, and National Government Services processes Medicare claims in Jurisdiction K.
New York medical billing →HealthChoices managed care plans cover most Medicaid children and families, and Novitas processes Medicare claims in Jurisdiction L.
Health Check is North Carolina's EPSDT benefit under NC Medicaid Managed Care, and Palmetto GBA processes Medicare claims in Jurisdiction M.
PeachCare for Kids is Georgia's CHIP program alongside Medicaid, and Palmetto GBA processes Medicare claims in Jurisdiction J.
See every state we serve, with each state's Medicaid program, Medicare contractor and filing limits.
Reporting from your family practice billing services should show revenue by age group, visit type and payer, because a gap in well-child visits looks different from a gap in Medicare wellness visits. Each month, RCM Xpert reports:
Outsourcing family practice billing services moves coding, payer follow-up and appeals off the physicians' and front desk's plates, while physicians keep full control of their documentation.
Family practice billing services are usually priced as a percentage of the payments collected or as a fixed fee per claim, and the rate depends on claim volume, payer mix, the share of Medicaid and vaccine claims, and which services are included. RCM Xpert quotes a rate after reviewing your actual claims in the Free Billing Audit, so the price reflects your practice rather than a generic rate card.
Moving your family practice billing to RCM Xpert follows five steps, and claims keep going out the whole time.
We review your recent claims, denials, preventive and vaccine billing and show you what we find.
We confirm provider enrollment with Medicare through PECOS, your state Medicaid program and its managed care plans, commercial payers and CAQH.
We connect to your EHR and clearinghouse under a signed Business Associate Agreement.
We bill alongside your current setup until the numbers match, then take over.
You receive your first monthly report by payer, provider and age group.
Family medicine billing services handle eligibility checks, coding, claim submission, payment posting, denial appeals and A/R follow-up for family physicians. Because family practices treat every age, the work covers well-child visits, vaccines, adult and Medicare preventive care, chronic disease visits and in-office procedures across Medicaid, Medicare and commercial plans.
Family practice billing combines both. Internal medicine bills adults and pediatrics bills children, while a family practice bills every age, so it uses all preventive age bands, both pediatric and adult vaccine administration codes, EPSDT rules for Medicaid children and Medicare wellness rules for older patients.
Yes. When the physician treats a significant new or worsening problem during a preventive visit, the practice bills the preventive code and a problem-oriented E/M with modifier 25. The record must document the problem separately. Minor issues handled within the checkup stay part of the preventive visit.
Each vaccine claim has a product line and an administration line. Patients through age 18 who receive counseling are billed 90460 and 90461 per vaccine component. Adults, or children without documented counseling, are billed 90471 to 90474 per vaccine. Every vaccine claim carries diagnosis code Z23.
The Vaccines for Children program supplies free vaccines for eligible children, including those on Medicaid or uninsured. The practice bills only the administration, and many state Medicaid programs require the vaccine product line at zero charge or with modifier SL to show the vaccine was state-supplied.
EPSDT is the Medicaid benefit covering preventive and follow-up care for enrolled children under 21. Well-child visits are billed with the age-based preventive codes, covered screenings such as developmental screening and fluoride varnish are billed alongside them, and some states require an EPSDT indicator on the claim.
Family physicians use 99381 to 99387 for new patients and 99391 to 99397 for established patients, chosen by age on the date of service. Medicare patients receive the Initial Preventive Physical Exam (G0402) once, then a yearly Annual Wellness Visit (G0438 first, G0439 after).
Yes. Family physicians can bill chronic care management for Medicare patients with two or more chronic conditions expected to last at least 12 months, after documenting consent and a care plan. Clinical staff time is billed with 99490 for the first 20 minutes each month and 99439 after that.
A family practice should consider outsourcing when its staff must keep up with age-based preventive codes, vaccine funding rules, state EPSDT requirements and Medicare wellness rules at once. Outsourcing puts that work with a team that bills it daily, while physicians keep control of their documentation.
RCM Xpert provides family practice billing services for every age group with certified coders, codes each claim from the provider's documentation, follows each state's Medicaid and EPSDT rules, reports by payer and age group every month, and starts with a Free Billing Audit of your recent claims.
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