First-Year Attending Billing Guide: Family Medicine Edition

Nobody Teaches Billing in Residency. Here's Your Crash Course.

You survived three years of residency. You can manage a complex panel, run a code, and deliver a baby. But somewhere between matching and your first day as an attending, nobody taught you how to get paid for the work you do. That's not an accident. Medical billing is barely covered in residency training, and the gap costs new attendings thousands of dollars in their first year.

This guide covers everything you need to know about billing in your first year of family medicine practice. No jargon. No fluff. Just the information that directly affects your paycheck and your patients.

What Changes When You Become an Attending

In residency, billing was someone else's problem. Your attending signed off on charts, the billing department submitted claims, and your salary stayed the same regardless. Now, everything changes:

• Your coding directly affects your income. Whether you're salaried with productivity bonuses or in an RVU-based compensation model, the codes you bill determine what you earn.
• You're the one signing the note. Your name is on the claim. Your documentation is what gets audited. Your coding patterns are what payers track.
• Nobody will tell you when you're under-coding. Your billing department submits what you select. If you're leaving money on the table, they may not flag it for months, or ever.

5 Things Residency Didn't Teach You About Billing

1. E/M Coding Is Simpler Than You Think

Since 2021, established patient E/M coding comes down to two paths: medical decision making (MDM) or total time. You choose whichever supports the higher code. For established patients (which will be most of your visits), here's the quick breakdown:

• 99213 (~$95): Low complexity. 1-2 stable chronic conditions, straightforward management. 20-29 minutes total time.
• 99214 (~$135): Moderate complexity. 2+ chronic conditions with mild exacerbation, prescription drug management. 30-39 minutes total time.
• 99215 (~$175): High complexity. 3+ chronic conditions being actively managed, drug requiring intensive monitoring, or care escalation decision. 40-54 minutes total time.

The $40 jump from 99213 to 99214, and the $40 jump from 99214 to 99215, adds up to tens of thousands of dollars per year. Your documentation has to support the code, but if you're managing chronic conditions (and you will be), you're probably doing 99214 work more often than you realize.

2. You're Probably Already Doing 99214-Level Work

National data shows new attendings in family medicine over-bill 99213 and under-bill 99214 compared to experienced providers seeing similar patients. The clinical work is the same; the difference is coding confidence. If your patient has diabetes and hypertension and you're adjusting medications, that's 99214. You don't need three conditions and a crisis to bill moderate complexity.

3. Time-Based Billing Is Your Friend

If MDM criteria feel intimidating, start with time-based billing. Document total time on every visit: chart review before the appointment, face-to-face time, documentation time, and any care coordination (calling a specialist, reviewing outside records). A single line at the end of your note ("Total time on date of encounter: 35 minutes") is sufficient. Many visits that feel like a "low" 99214 on MDM clearly qualify as 99214 or even 99215 on time.

4. Add-On Codes Exist and You Should Bill Them

Your base E/M code isn't the only revenue from a visit. Family medicine has several add-on codes that most new attendings never learn about:

• G2211 (~$16): Visit complexity add-on for ongoing chronic care management. Applies to most established patient visits with chronic conditions. No extra documentation needed.
• 99417 ($43 per 15 min): Prolonged services add-on for visits exceeding the time threshold of the highest E/M code (55+ minutes). Bill in 15-minute increments.
• 99441-99443 ($28-$78): Telephone E/M services. When you spend 5+ minutes on a medical phone call with a patient (not just refill requests), you can bill for it.

5. Phone Calls and After-Hours Work Are Billable

That 15-minute phone call where you adjusted a patient's insulin regimen? That's billable. 99442 covers 11-20 minutes, approximately $56. The 25-minute call managing an anxious patient's acute symptoms to avoid an ER visit? 99443, approximately $78. Most new attendings do this work for free because nobody told them a code exists.

Your Daily Code Toolkit

Here are the codes you'll use almost every day, with approximate 2026 Medicare reimbursement:

• 99213 ($95): Your bread-and-butter low-complexity visit
• 99214 ($135): Your most common code, since most chronic disease visits land here
• 99215 ($175): Complex patients, multiple active problems, drug-monitoring visits
• G0439 ($138): Subsequent Annual Wellness Visit (the yearly Medicare preventive visit)
• G2211 ($16): Add to qualifying 99212-99215 visits for chronic care complexity
• 99395/99396 ($155-$170): Preventive visit for established patients (commercial insurance)

Working With Your Billing Team

Your billing team is your most important ally in your first year. Build that relationship early:

• Ask for your code distribution monthly. Request a report showing your E/M code breakdown. Track it over your first 6 months and watch it evolve.
• Ask about denials. Find out which of your claims are getting denied and why. Common first-year denial reasons: missing modifier -25, insufficient documentation for the level billed, and duplicate billing errors.
• Ask for a coding review. Many practices offer periodic chart reviews where a certified coder evaluates whether your documentation supports your codes. Request one in your first 3 months.

Pro tip: If your practice has a certified coder on staff, ask them to review 10 of your charts after your first month. The feedback will be worth more than any billing lecture you could attend.

The Codes You're Probably Missing

Beyond the daily E/M codes, new attendings consistently miss revenue from:

• Same-day split billing: When you address a medical problem during an AWV, bill both with modifier -25. That's $95-$135 in extra reimbursement per occurrence.
• Chronic care management (CCM): 99490 pays ~$62/month per qualifying patient for 20+ minutes of non-face-to-face care coordination. If your MA is making care calls and coordinating referrals, this is billable.
• Transitional care management (TCM): 99495/99496 pays $185-$262 for post-discharge follow-up within 7-14 days. Most practices miss this entirely.

5 First-Month Action Steps

1. Document total time on every visit. Start today. One line at the end of your note. This gives you the option to bill by time when it supports a higher code.
2. Meet with your billing team. Introduce yourself, ask about the claim submission process, and request monthly code distribution reports starting now.
3. Learn the 99213/99214/99215 criteria. Print the MDM table and keep it at your desk for the first month. Within a few weeks, you'll internalize it.
4. Add G2211 to your workflow. For every established patient visit involving chronic disease management, add G2211. At $16/visit, this alone could add $3,000+/month to your practice revenue.
5. Use Pika to find your gaps. Run your first Pika analysis to see where your billing compares to family medicine benchmarks. It takes 5 minutes and shows you exactly where to focus.

Billing isn't glamorous, and it's not why you went to medical school. But understanding it in your first year sets the foundation for your entire career, whether you stay in employed practice, go independent, or lead a group. The providers who learn billing early earn more, document better, and spend less time fighting denials. Start now.