What is the recommended billing level for a Medicare patient establishing care with a new primary care provider (PCP)?

Billing Level for Medicare Patient Establishing Care with New Primary Care Provider

For a Medicare patient establishing care with a new primary care provider, bill using CPT code 99204 or 99205 (new patient office visit codes) based on the complexity of the encounter, NOT the preventive medicine codes (99386/99387), unless the visit is specifically for a Medicare Annual Wellness Visit (AWV) using G-codes G0438 or G0439. 1

Understanding the Distinction

The critical issue here is clarifying what type of visit this represents:

If This is a Problem-Oriented "Establish Care" Visit:

• Use new patient E/M codes 99201-99205 (though 99201 was deleted in 2021, so effectively 99202-99205) 2
• Code selection depends on three key components: history, physical examination, and medical decision-making 2
• For new patients, all three key components must meet or exceed the level you're billing 2
• Most "establish care" visits for Medicare patients with chronic conditions will qualify for 99204 (moderate complexity) or 99205 (high complexity) 3

If This is Specifically a Medicare Annual Wellness Visit:

• Use G0438 (initial AWV, "Welcome to Medicare" visit within first 12 months of Part B) or G0439 (subsequent AWV) 1
• These are distinct from preventive medicine codes and have specific Medicare requirements 4
• Medicare covers these at 100% with no cost-sharing when billed correctly 1

Coding Level Selection Algorithm

For problem-oriented new patient visits (99202-99205):

1. Document comprehensively - The level of documentation directly determines your billing level 5, 6

2. Assess complexity based on:

   • Number of problems addressed - More problems = higher level 3
   • Patient's medical conditions - Chronic diseases increase complexity 3
   • Medical decision-making complexity - Review of systems, medication reconciliation, care coordination 6

3. Common pitfall: Residents and less experienced providers tend to undercode by 30-40% compared to attending physicians for identical visits 3

4. For typical Medicare "establish care" visits: Most will be 99204 or 99205 because Medicare patients typically have:

   • Multiple chronic conditions requiring management 4
   • Medication reconciliation needs 4
   • Care coordination requirements 4

Critical Documentation Requirements

To support higher-level billing (99204/99205):

• Comprehensive history: Include all relevant past medical, family, and social history 1
• Comprehensive examination: Document all pertinent body systems 1
• Medical decision-making: Document complexity of problems, data reviewed, and risk 6
• Time documentation: Only use time as the determining factor if counseling/coordination dominates >50% of the visit 2

Common Billing Pitfalls to Avoid

• Do NOT use preventive medicine codes (99386/99387) for standard "establish care" visits with Medicare patients - these are for private insurance preventive visits 1
• Do NOT undercode - Accurately reflect the complexity of care delivered, as this is a known revenue loss issue 6, 3
• Do NOT use old level-of-service codes - Only current CPT E/M codes are valid 2
• Ensure proper documentation - Incomplete documentation is the primary cause of coding discrepancies and denials 5, 6

Billing for Additional Services

If you address both preventive care AND acute/chronic problems:

• Bill the primary visit code (99204/99205 or G0438/G0439) 1
• Add modifier -25 to the problem-oriented E/M code if billing both preventive and problem visits same day 1
• Document clearly which services were preventive versus problem-focused 1

Payment Considerations

• Medicare reimbursement rates are higher for 99204/99205 than lower-level codes, and accurate coding can increase revenue by over $230,000 per 10,000 encounters 6
• Medicaid rates historically pay only 58% of Medicare rates for primary care, though this varies by state 4
• The Centers for Medicare & Medicaid Services has increased fees for E/M visits and lowered documentation requirements to better support primary care 4