Medical billing and coding: Optimize documentation and payment

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Get paid for the care you deliver. Access tools and resources to improve coding accuracy, streamline documentation and maximize payment.‌‍‌​​‌​‍​‌

Why accurate coding matters

Accurate coding supports payment, reduces audit risk and captures the complexity of the care you provide. Get guidance on key billing and coding topics and specific service codes to help you document accurately, get paid appropriately and manage your practice efficiently.​​‌

30K

Average lost revenue per year from undercoding a few times a day

Thomas Weida, MD, FAAFP

Code sets by service type

Browse resources that show how to accurately code for some of the most common services family physicians offer.

  • Advanced care planning

    Time spent with patient, family member, or surrogate to explain and discuss advance directives. ACP codes

  • Advanced primary care management

    Payment for resources associated with providing advanced primary care to patients. APCM codes

  • Annual wellness visit

    Medicare service to review the patient’s wellness and develop a personalized prevention plan. AWV codes

  • Behavioral health integration

    Additional care management services patients with mental, behavioral health, or psychiatric conditions. BHI codes

  • Chronic care management

    Non-face-to-face services provided to Medicare beneficiaries who have multiple chronic conditions. CCM codes

  • Group visits

    Management of patients with chronic conditions in a group setting. Group visit codes

  • Initial Preventive Physical Examination/Welcome to Medicare

    Preventive visit offered to newly-enrolled Medicare beneficiaries. Group visit codes

  • Medicare non-covered services

    Two categories remain largely non-covered by Medicare. Non-covered services

  • Newborn care

    Services provided to normal newborns in the first days of life prior to hospital discharge. Newborn visit codes

  • Transitional care management

    Address the hand-off period between the inpatient and community setting. TCM codes

Billing and coding systems education

You need a solid grasp of the basics to stay compliant and keep your documentation in good shape. Learn how code sets that are part of everyday practice work and should be used.

Infographic depicting the path from visit to payment.

Coding basics: HCPCS, CPT and ICD-10 for physicians​​

  • HCPCS allows physicians to document the services provided. ICD-10 Codes are placed on health insurance claims to convey to insurance companies the reason for the encounter. Learn coding basics.

Hierarchical Condition Category (HCC) coding

  • Hierarchical condition category coding helps communicate patient complexity and paint a picture of the whole patient. Find out more.

Evaluation and management coding

  • E/M visits are the everyday visits where you assess patients’ health, take histories and make care decisions. Get the details.

Using Modifier 25 correctly

  • Modifier 25 can capture additional E/M services provided on the same day, and questions about it have increased in recent years. Read about when to use it.

Billing for non-physician clinician services

Best practices for medical billing and documentation

  1. Stay current on coding changes through regular training, reviewing documentation and keeping up with coding updates.

  2. Using time-based codes correctly and applying the right modifiers can also help ensure you’re paid appropriately.‌​‌‌​​‌‌‌‌

  3. Optimize revenue under FFS by implementing Medicare services that promote value-based care.

  4. Accurately document your visits while implementing ways reduce the administrative burden associated maintaining thorough records.

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