5 billing and coding tips for residents and new attendings

By Erin Solis

There’s a lot to adjust to when you’re fresh out of residency, especially when it comes to coding. How well you are paid is partially determined by how well you can code.

How much does it really matter? One family medicine expert estimated that some family physicians are losing more than $30,000 a year due to under-coding, so let’s make sure you get paid appropriately for your hard work.

Learning to accurately capture all the services you’re providing means more RVUs, and helps avoid denials, which take time and money to correct. Coding accurately also helps you keep track of your patients’ care and stay in compliance with payer policies and regulations.

Remember when you were a kid and your parents told you it was illegal to turn on the overhead light in a moving car? I have another one for you. Have you been told that you cannot report a preventive service and a problem-focused E/M service at the same encounter? Well, just like there actually isn’t a law against turning on the overhead light, there is also no CPT or Medicare rule that prohibits reporting both preventive and E/M services at the same encounter.

A problem-focused (i.e., office visit) E/M may be reported with a preventive visit if the problem is significant enough to warrant additional work to perform a problem-focused E/M service (although commercial policies may vary, so check with your local provider relations representatives for their policies). In these instances, you may report the appropriate office/outpatient E/M code in addition to the preventive service. You would append modifier 25 to the E/M code. Your documentation must be clear that the E/M was a significant and separate service. In other words, both services (and documentation) must be able to stand alone as an individual service.

It’s also a good idea to let the patient know that they may have a copay for the problem-focused portion of the visit.

Now, just because you can bill an E/M with a preventive service, it doesn’t mean you always should. As with the overhead light, it’s really only necessary in certain circumstances. An insignificant or trivial problem that does not require additional work or performance of the key components of an E/M service should not be reported separately.

Speaking of preventive services, these can be high-value services that are easily overlooked:

Those are just a few examples of billable preventive services to know from CMS’s full list of Medicare Preventive Services.

Again, it’s important to pay attention to modifiers when reporting preventive services with an E/M service. For example, you’ll need to add modifier 25 to your E/M if you are also reporting a depression screening (HCPCS G0444). Keep in mind that many preventive services are time-based services and you will need to document time in the record.

Advance care planning (CPT codes 99497 and 99498) is another high-value opportunity. Many practices incorporate it as part of a patient’s annual wellness visit, where it is exempt from beneficiary cost-sharing. (Make sure you add modifier 33 to the ACP code.) ACP is not limited to the AWV. It can be performed at any E/M visit. However, it is subject to cost-sharing when it is provided outside of the AWV. Like the preventive services, ACP is a time-based code.

Modifiers keep coming up. That’s because modifiers are a small thing that can make a huge difference. They’re kind of like salt. Often adding a little salt can be the difference between a dish being a success and a dish getting tossed in the bin. Similarly, modifiers can often be the difference between a claim getting paid and a claim getting denied.

The modifier you will use the most is modifier 25. It represents “a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.” Here are a few questions that can help you determine whether it’s appropriate to use modifier 25:

Keep these questions in mind when you are reporting an E/M on the same day as a procedure or preventive service. Sometimes a dash of modifier 25 is all you need to make your claim a success.

You may have heard of G2211, but are you consistently using it? If you aren’t, you are missing out. G2211 is a handy add-on code that can be reported with office/outpatient E/M (CPT codes 99202-99215) and home/residence E/M (CPT codes 99341-99350) services. And the best part is that it applies to the majority of primary care encounters. Here’s why:

Medicare introduced G2211 in 2024 to reflect the inherent complexity associated with serving as the focal point for a patient’s health care needs or providing ongoing care for serious or complex conditions. Sounds a lot like family medicine, yes? Medicare created G2211 to acknowledge the fact that the longitudinal and comprehensive nature of primary care isn’t fully reflected in the RVUs of the office/outpatient E/M codes. They expanded G2211 to home/residence services starting in 2026.

Though primary care is complex, reporting G2211 is not. The key to G2211 is the relationship between the patient and the physician. If you have or intend to take responsibility for the continuous, comprehensive and longitudinal care of the patient, G2211 is for you. Simply report it as an add-on code with your office/outpatient or home/residence E/M services. It applies to traditional Medicare as well as most Medicare Advantage plans. Private and Medicaid coverage will vary.

This wouldn’t be a coding blog without a couple of caveats. Not surprisingly, they are related to our old friend modifier 25, and G2211 and modifier 25 have a complicated relationship.

This is a change from Medicare’s previous policy that restricted reporting G2211 with any E/M appended with modifier 25.

Most family physicians tend to default to using medical-decision making to select their level of E/M service. Considering the comprehensive nature of primary care, it makes sense that using medical decision making (MDM) tends to be the option that most often captures the work.

But some visits may not rise to a higher level of MDM but instead require significant time. Examples include visits that require extensive record review or involve lengthy counseling conversations with the patient. You still did the same amount of work, but it may not be reflected in the MDM. In such instances, using total time may be a better way to capture the complexity of the visit. Total time includes all the time you spent in care of the patient on the date of the encounter, such as reviewing previous notes in preparation for the visit, counseling and educating the patient, communicating with other health care clinicians or documenting in the EHR. If it is personally performed by you and occurs on the date of the encounter, it can count toward total time—regardless of whether it occurred before, during or after you saw the patient.

Whichever method you use, make sure your documentation supports the level of service billed. (If you had a dime for every time you’ve heard that, right?). If using total time, give a high-level breakdown of how you met or exceeded the code’s time threshold. It’s a compliance red flag if all your notes list the same time, and an even bigger red flag if the time listed is just the code’s minimum threshold. If you select your E/M based on total time and are reporting other time-based services, make sure you only count time once. In other words, time spent providing the other service cannot also count toward an E/M’s total time.

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Finally, the family physician I mentioned at the beginning of this post who estimated how much is being lost to under-coding, Thomas Weida, MD, FAAFP, will be among the expert speakers sharing billing and coding tips at FMX to help you improve coding and reduce denials. During the Oct. 20-24 event in Nashville, his session on transitional care management and Medicare Annual Wellness Visits will include guidance on applying documentation guidelines to reduce claim denials.

With these tips you can feel more confident in your coding and documentation. Yes, coding is important. But it’s even more important that you get paid for the comprehensive care you provide. You work hard, so don’t leave money on the table.

Erin Solis is the AAFP’s payment strategies manager. In this role, she serves as a subject matter expert to support the Academy’s payment advocacy efforts. She also supports the development of AAFP payment, billing and coding resources.