Practice type: Independent family medicine practice group Providers: 2 physicians, 1 nurse practitioner Location: United States Patient volume: Approximately 1,800 patient encounters per month Payer mix: 38% Medicare, 34% commercial (BCBS, Aetna, UHC), 18% Medicaid, 10% self-pay Services: Preventive care, chronic disease management, acute sick visits, in-office procedures, telehealth, Annual Wellness Visits
Background
This practice had been operating for nine years when they contacted Malakos Healthcare Solutions. Three providers, a stable patient panel, and a billing operation that had been managed in-house since the practice opened.
The front office manager handled billing alongside scheduling, insurance verification, and patient communications. One part-time billing assistant processed charges and posted payments. Neither had specialty billing training. Both had learned on the job, primarily from the EHR’s billing module and an occasional webinar.
On the surface the practice looked financially stable. Collections were consistent month to month. The physicians were compensated appropriately. Nobody was panicking.
What prompted the call to Malakos wasn’t a crisis. It was a conversation at a regional physician conference where one of the partners heard a colleague describe the CCM billing program and realized she had never heard of it.
“I came back from that conference and asked our front office manager if we were billing for chronic care management,” she told us during our first call. “She didn’t know what it was either. That was the moment I thought maybe we should have someone take an actual look at what we’re doing.”
That conversation led to a billing audit. The audit changed everything.
The Initial Audit – What We Found
Malakos conducted a full revenue cycle audit covering twelve months of claims data, six months of ERA and EOB records, the complete AR aging report, and a documentation review of forty patient encounters sampled across all three providers.
What the audit revealed was a billing operation that was functional but years behind current coding guidelines, missing entire categories of reimbursable services, and quietly accepting underpayments that had been accumulating since the practice opened.
Finding 1 – Chronic Care Management: Zero Claims, Hundreds of Qualifying Patients
The practice had never submitted a single CCM claim in nine years of operation.
A review of the active Medicare patient panel identified 187 patients with two or more documented chronic conditions meeting CCM eligibility criteria hypertension and diabetes, COPD and heart failure, depression and chronic musculoskeletal pain, hypothyroidism and obesity. The care coordination work was happening — phone calls between visits, medication reconciliation, care plan updates, referral coordination. It simply was never billed.
At Medicare’s current reimbursement for CPT 99490 (first 20 minutes of clinical staff time per month), 187 qualifying patients represented approximately $7,854 in monthly revenue that the practice was generating and not collecting. Annually: $94,248 nearly $100,000 per year in care coordination work that went uncompensated for nine years.
The reason wasn’t negligence. It was simply that nobody in the practice knew the billing codes existed, and the EHR’s default charge capture workflow didn’t prompt for monthly CCM billing.
Finding 2 – E/M Undercoding Across All Three Providers
The forty-encounter documentation sample showed consistent undercoding across all three providers. The distribution was striking:
- 91% of established patient visits were billed at 99213
- 8% at 99214
- 1% at 99215
- 0% using time-based billing despite multiple documented encounters exceeding 30 minutes of total time
Under 2021 AMA E/M guidelines, medical decision-making complexity determines the code level not the number of elements documented. A review of the sampled encounters showed that 68% of the encounters billed at 99213 documented complexity that supported 99214:
- Managing two or more chronic conditions with medication adjustment
- Ordering and reviewing diagnostic results (labs, imaging)
- Prescription drug management with documented risk of drug-drug or drug-condition interaction
- Care coordination with specialists or other providers
- Independent interpretation of in-house ECG or spirometry results
The front office manager had been trained to bill 99213 for “standard visits” and 99214 only for “complex visits” — a guideline built on the old three-key-component framework that was eliminated in 2021. The providers had never been informed that the coding rules changed.
The financial impact of defaulting to 99213 when 99214 was supported: approximately $38 per visit under Medicare, across approximately 900 established patient visits per month. Conservative extrapolation suggested the practice was leaving $25,000–$32,000 per month $300,000–$384,000 per year in E/M revenue on the table. Even applying the 68% qualifier, the annual undercoding gap was approximately $204,000.
Finding 3 – Annual Wellness Visits Billed as Standard E/M Visits
The audit identified 340 Medicare Annual Wellness Visits in the twelve-month period. Of those, 218 had been billed as standard office visit E/M codes (99213 or 99214) rather than as AWV codes (G0438 or G0439).
The billing impact was two-directional. For patients where the AWV was billed as 99213, the practice collected the 99213 rate rather than the higher AWV reimbursement. For patients where both a preventive visit and a problem were addressed and both should have been billed AWV plus E/M with Modifier 25 only the E/M had been submitted.
Additionally, the AWV coding errors had a patient experience consequence: some patients were receiving explanation of benefits showing cost-sharing charges for what should have been a no-cost preventive benefit, generating calls to the front desk and occasional patient complaints.
Estimated annual revenue gap from AWV coding errors: $18,600.
Finding 4 – Modifier 25 Missing on Same-Day Combination Visits
A review of dates where both a preventive visit code and a problem-focused E/M should have appeared on the claim showed that in 73% of cases, only the preventive visit was billed. The problem-focused E/M the additional clinical work performed when the provider addressed a separate issue during the wellness visit was not submitted.
This wasn’t a deliberate billing decision. It was a workflow gap: the charge ticket captured the preventive visit code, and the separate E/M with Modifier 25 was simply never entered.
Annual impact from missing Modifier 25 combination visits: estimated $22,400.
Finding 5 – Transitional Care Management Never Billed
The practice managed a meaningful number of post-hospitalization transitions per month reviewing discharge summaries, reconciling medications, contacting patients within two business days of discharge, and seeing them in the office within two weeks. This is exactly the clinical scenario TCM codes are designed to compensate.
Twelve months of hospital discharge data identified 94 encounters that qualified for TCM billing. Zero had been billed.
At an average of approximately $180 per TCM encounter under Medicare, the missed annual TCM revenue was $16,920.
Finding 6 – Telehealth Claims With Wrong Place of Service Code
The practice had adopted telehealth during the COVID period and maintained a telehealth schedule of approximately 120 visits per month. A review of telehealth claims showed that 84% were being submitted with POS 11 (office) the standard in-person office visit code rather than POS 10 (telehealth, patient’s home), which applied to the vast majority of their telehealth visits.
Beyond the reimbursement implications, billing telehealth visits with POS 11 is a documentation mismatch that creates audit exposure. If a payer or CMS audited those claims and found that POS 11 was applied to visits where the patient was at home and the provider was conducting the visit remotely, the compliance consequences could extend beyond the individual claims reviewed.
The practice was not aware this was wrong. They had been billing telehealth the same way they billed in-person visits because no one had told them the rules were different.
Finding 7 – In-Office Procedures Underreported
A charge capture review identified three categories of in-office procedures that were being performed but inconsistently billed:
ECG interpretation: The practice performed approximately 40 ECGs per month. CPT 93000 (ECG with interpretation and report) was billed on 31 of those. The remaining nine showed an ECG was performed in the clinical note but no charge was entered.
Vaccine administration codes: Vaccine product codes were captured consistently. The administration codes (90471 for the first injection, 90472 for each additional) were missing on approximately 18% of vaccine encounters.
Tobacco cessation counseling: Three providers were regularly documenting tobacco cessation counseling in visit notes. CPT 99406 (3-10 minutes) and 99407 (greater than 10 minutes) were being billed on none of these encounters.
Combined annual impact of underreported procedures: estimated $14,800.
Audit Summary
| Revenue Gap | Annual Estimated Impact |
|---|---|
| CCM never billed (187 qualifying patients) | $94,248 |
| E/M undercoding (99213 vs 99214) | $204,000 |
| AWV coding errors | $18,600 |
| Missing Modifier 25 on combination visits | $22,400 |
| TCM never billed | $16,920 |
| Telehealth POS code errors | $12,400 |
| Underreported in-office procedures | $14,800 |
| Total identified revenue gap | $383,368 |
The audit meeting with the two physicians and the front office manager lasted two hours. The number that created the most immediate reaction wasn’t the E/M undercoding it was the CCM figure.
“We’ve been doing this work for nine years and never got paid for it once,” one of the physicians said. “That’s not a billing mistake. That’s just not knowing what you don’t know.”
The practice signed with Malakos the following week. The front office manager, to her credit, was relieved rather than defensive. “I’ve been doing my best with what I knew,” she said. “I didn’t know how much I was missing.”
The Transition – First 30 Days
Onboarding took thirteen business days. The practice used eClinicalWorks. Malakos continued working within eClinicalWorks no migration, no disruption to scheduling or patient care workflows.
The first priority was compliance risk mitigation. The telehealth POS code errors represented the most immediate compliance exposure. We conducted a retroactive claims review going back six months and prepared a voluntary disclosure assessment — identifying the scope of the POS 11 error, quantifying the claims affected, and advising the practice on corrective action options before any payer initiated an audit.
The second priority was building the CCM infrastructure. This involved three steps: identifying and confirming the 187 qualifying patients with documented chronic conditions, developing a standard consent and care plan template that met Medicare’s CCM requirements, and building a monthly time-tracking and billing workflow into the practice’s existing care coordination activities. The first batch of CCM claims went out at the end of the first full billing month.
The third priority was provider documentation briefing. Both physicians and the NP received a one-page E/M coding reference not a lecture on billing compliance, but a practical guide showing the specific documentation elements that distinguish 99213 from 99214 under current guidelines. The message was simple: the complexity of care you’re already delivering supports higher code levels. The documentation you’re already writing supports it. The code level just needs to reflect it.
90-Day Results
At the 90-day performance review:
CCM billing launched and stable: Month one: 143 patients enrolled and billed (not all 187 immediately consent collection took time). Month two: 171 patients. Month three: 187 patients fully enrolled. Monthly CCM revenue at month three: $7,854. On track for $94,248 annually from a revenue stream that had never existed before.
E/M code distribution shifted materially:
| Code | Pre-Malakos | 90 days after |
|---|---|---|
| 99212 | 4% | 3% |
| 99213 | 91% | 38% |
| 99214 | 4% | 54% |
| 99215 | 1% | 5% |
Every code level change was supported by documented clinical complexity in the corresponding encounter. No upcoding the providers were simply documenting and billing the level of care they were actually delivering.
AWV billing corrected: G0438 and G0439 applied correctly to all Medicare wellness visits. Combination visits billed with Modifier 25 on the problem-focused E/M code. AWV-related patient billing complaints dropped to zero within 60 days.
Telehealth compliance addressed: POS 10 applied to all patient-home telehealth visits. POS 02 applied to facility-based telehealth. Modifier 95 applied to commercial payer telehealth claims. Voluntary disclosure process completed. No payer audit initiated.
Days in AR: Pre-Malakos: 54 days average. 90 days after: 38 days average. Improvement driven by faster charge entry, same-week claim submission, and structured AR follow-up replacing the previous weekly batch process.
12-Month Results
At the twelve-month mark, the practice’s annual revenue comparison showed the following:
| Metric | Pre-Malakos | 12 months with Malakos |
|---|---|---|
| Total net collections | $2,106,000 | $2,393,000 |
| CCM monthly billings | $0 | $7,854 |
| Overall denial rate | 14.2% | 5.9% |
| Days in AR | 54 days | 36 days |
| E/M visits at 99214+ | 5% | 59% |
| AWV coding accuracy | 36% | 98% |
| Modifier 25 capture rate | 27% | 94% |
| TCM billing capture | 0% | 91% |
Total revenue improvement year-over-year: $287,000
The gap between the $383,000 identified in the audit and the $287,000 recovered in year one reflects two realities: some revenue gaps particularly E/M level improvements ramp up gradually as documentation habits adjust, and some of the audit estimates were conservative baselines rather than guaranteed recoveries. Year two projections, with CCM fully enrolled and E/M habits fully adjusted, put the practice on track to close most of the remaining gap.
What the Practice Said
At the one-year review, the conversation was notably different from the first call.
“The CCM program alone paid for everything,” one of the physicians said. “We’re collecting $7,800 a month for care coordination work we were already doing. If I had known about this nine years ago I would have implemented it nine years ago.”
The front office manager had a different observation:
“What surprised me most was how much the billing changes didn’t change anything for our patients or our staff. We didn’t add new services. We didn’t change how the physicians practice. We just started billing correctly for what we were already doing. The revenue went up because we stopped leaving it on the table.”
The NP, who had been the most skeptical of the transition initially, noted the practical impact of the E/M documentation guidance:
“I was billing 99213 for almost everything because I didn’t want to get audited for upcoding. What I didn’t understand was that I was actually protected from audits by billing the correct level with complete documentation — not the conservative level. That was a mindset shift.”
Key Takeaways
CCM is the largest untapped revenue stream in family medicine. Most family medicine practices have dozens or hundreds of qualifying Medicare patients and zero CCM claims. The work is already happening. The billing infrastructure just needs to be built.
E/M undercoding after the 2021 changes is nearly universal. The AMA changed the rules four years ago. Most in-house billing teams haven’t fully adjusted. The financial impact is significant and immediate once corrected.
Compliance risk from telehealth billing errors is real and growing. POS code errors are one of the most common audit targets for Medicare telehealth claims. Fixing them proactively is far less expensive than addressing them after a payer initiates a review.
The revenue was always there. The practice didn’t grow its way to $287,000 in additional collections. It didn’t add services, add providers, or add hours. It billed correctly for what it was already delivering. That distinction matters — because it means the same opportunity is sitting in most family medicine practices right now, waiting for someone to look for it.
Is Your Family Medicine Practice Missing Similar Revenue?
If your practice hasn’t had an independent billing audit in the past twelve months and particularly if CCM billing, E/M optimization, and telehealth compliance aren’t currently active priorities in your billing operation there is almost certainly a version of this story sitting in your revenue cycle.
Malakos Healthcare Solutions offers a free family medicine billing audit that identifies your specific revenue gaps in dollar terms not industry benchmarks, not estimates. Your practice’s data, your practice’s gaps, your practice’s recovery opportunity.
No commitment. No obligation. Just a clear picture of what your billing operation is actually capturing and what it’s leaving behind.
Schedule Your Free Family Medicine Billing Audit
📞 +1 (307) 441-3431 ✉️ support@malakoshcs.com 📍 Cheyenne, Wyoming – Serving family medicine and general practice groups nationwide
This case study represents a composite of common billing challenges and outcomes seen across family medicine practices. Practice details have been generalized to protect confidentiality.
Malakos Healthcare Solutions | Family Medicine Billing Services USA | Serving independent family medicine and general practice groups nationwide since 2022
