We run billing for independent primary care and family medicine practices: preventive and problem visits on the same day, Medicare wellness visits, transitional and chronic care management, inside the EHR you already use.
“I appreciate that you did an audit and found out the root causes of a lot of my problems which are preventable.”
Primary care billing
Primary care claims are small and many, so the losses hide in volume. A visit coded one way when the note supports another, a wellness visit booked a month early, a discharge noticed too late to call. None is large on its own. Across a panel, they add up to more than any single denial.
A problem managed during a preventive visit is separate work when it is significant. Billed as preventive only, it is lost. Billed with modifier 25 for something trivial, or with the modifier on the wrong line, it is the claim payers audit.
The IPPE denies once the patient is past their first 12 months of Part B. G0438 is once in a lifetime, and an AWV inside 12 months of the last IPPE or AWV denies. Each is a timing check that belongs before the visit is booked.
TCM pays well and is easy to lose: no record of the contact within two business days, a face-to-face visit on day 15, or another practice billing the same 30 days first.
Chronic care management needs consent on file, an initiating visit and a monthly count of minutes. Without the count there is no claim, and without consent the claim does not hold.
The add-on for the continuing relationship primary care has with its patients goes missing from follow-up visits, or is dropped on wellness-visit days, when Medicare has paid it alongside modifier 25 in that case since 2025.
Preventive visits
Medicare's wellness benefit is not a physical. It pays for the initial preventive physical examination in the first 12 months of Part B and for the annual wellness visit after that, each on its own timing rule, and the patient owes no deductible or coinsurance for the AWV. Traditional Medicare does not pay the preventive medicine codes for patients 65 and over.
When a problem is managed in the same visit and the work is significant and separate, it is billed as its own office visit with modifier 25 on that line. The patient's cost sharing applies to that part, so they should hear about it at the visit, not from the statement.
| Code | What it is | Where claims go wrong |
|---|---|---|
| G0402 | Initial preventive physical examination (IPPE), once, within the first 12 months of Part B enrollment | Billed after month 12, when it denies automatically |
| G0438 | Initial annual wellness visit, once in a lifetime | Billed again for a patient who has already had one |
| G0439 | Subsequent annual wellness visit, yearly | Billed within 12 months of the patient's last IPPE or AWV |
| 99497 + 33 | Advance care planning with the AWV, same day, same provider | Billed without modifier 33 on the AWV claim, so the patient owes coinsurance and deductible |
| 99381–99397 | Preventive medicine visits by age, for commercial and Medicaid plans | Sent to traditional Medicare, which does not pay the codes for patients 65 and over |
| 99202–99215 + 25 | A problem-oriented visit on the same day as the preventive visit | Modifier 25 put on the wellness or vaccine line instead of the problem visit |
The problem visit needs work beyond what the preventive visit already includes. A trivial problem, or one handled inside the wellness exam, does not support a second claim, and the modifier is not meant to be added routinely. The note has to show the additional work.
Advance care planning is time-based: 99497 for the first 16 to 30 minutes, 99498 for each additional 30. Furnished with the AWV, on the same day, by the same provider and billed with modifier 33 on the same claim, Medicare waives the deductible and coinsurance. Outside the AWV, the patient pays both.
Medicare does not pay G2211 on a visit billed with modifier 25, with one exception since 2025: when the other same-day service is an annual wellness visit, a vaccine administration or a Part B preventive service.
The IPPE belongs in the first 12 months of Part B, and an AWV cannot follow an IPPE or another AWV within 12 months. Both dates are known before the visit is booked, which is where the check belongs.
Source: First Coast, annual wellness visits · ACP Internist, preventive services in Medicare · Medical Mutual, wellness and sick visit on the same day
Transitions
TCM covers the 30 days after a patient leaves a hospital, an observation stay, a skilled nursing facility or a similar inpatient setting for home or another community setting. The period starts on the day of discharge.
There are two codes, split by complexity and speed. 99495 needs at least moderate medical decision making and a face-to-face visit within 14 calendar days. 99496 needs high complexity and a visit within 7. Both need contact with the patient or caregiver within two business days of discharge, by phone, email or in person, by clinical staff who can deal with more than scheduling.
Two or more separate, timely attempts, each documented, still meet the requirement, as long as the practice keeps trying until it reaches the patient.
Only one physician or practitioner can report TCM for the 30 days, once per patient. If another practice bills it first, the second claim denies.
A face-to-face visit outside the window means TCM cannot be billed. The visit cannot fall on the same day as discharge day management, and a practitioner cannot bill TCM inside their own post-operative global period.
Chronic care management can be billed in the same 30 days when it is reasonable and necessary and the same minutes are not counted twice.
Source: CMS MLN908628, Transitional Care Management Services
Care management
Care management pays for the work between visits: calls, medication reconciliation, coordination with specialists, the care plan itself. Each code family has its own threshold, and each needs the paperwork in place before the first claim.
| Code | What it pays for | What has to be on file |
|---|---|---|
| 99490 / +99439 | Chronic care management, clinical staff time: the first 20 minutes, then each additional 20 | Consent, an initiating visit, a care plan and the month's minutes |
| 99491 / +99437 | Chronic care management by the billing practitioner: the first 30 minutes, then each additional 30 | Only the practitioner's own time counts, not clinical staff time |
| 99487 / +99489 | Complex chronic care management, clinical staff time: the first 60 minutes, then each additional 30 | The same consent and care plan, with time to match |
| 99424–99427 | Principal care management for one high-risk chronic condition | At least 30 minutes in the calendar month; nothing under 30 is billable |
| G0556–G0558 | Advanced primary care management, one monthly code by patient complexity | No minute count; the level follows chronic conditions and QMB status |
| 99445 / 99470 | Remote physiologic monitoring: 2 to 15 days of data, and management under 20 minutes a month | New for 2026; 99445 and 99454 are never billed for the same monitoring period |
Before the first claim, the patient agrees, in writing or verbally, after being told the service exists, that cost sharing may apply, that only one practitioner can bill it in a calendar month, and that they can stop at any time. Consent is needed once, unless the patient moves to another practitioner.
New patients, and patients not seen within the past year, need an initiating visit first: a comprehensive E/M visit, an AWV or an IPPE where care management is discussed. G0506 can be billed once with it when the practitioner does extensive assessment and care planning beyond the usual work.
G0556 for patients with no or one chronic condition, G0557 for two or more, G0558 for two or more with Qualified Medicare Beneficiary status. It is billed once a calendar month and bundles elements of chronic, principal and transitional care management, interprofessional consultations and online digital visits.
For 2026, CMS added three optional behavioral health add-ons, G0568 to G0570, billed when the same practitioner reports APCM that month.
Device supply used to need 16 days of data in the period, the 99454 threshold. 99445 now covers 2 to 15 days, and 99470 covers management under 20 minutes a month. Only one of 99445 and 99454 is reported per monitoring period.
Source: CMS MLN909188, Chronic Care Management Services · CMS MM14315, CY2026 PFS final rule summary · Noridian, RPM 2026 updates
Visits
Most primary care is a long relationship, and that is the work G2211 was created for. Medicare has paid the add-on with office and outpatient visits since 1 January 2024 when the practitioner is the continuing focal point for the patient's care, or is managing a serious or complex condition over time.
It is not paid when the visit carries modifier 25 for a same-day procedure, except, since 2025, when the other same-day service is an annual wellness visit, a vaccine administration or a Part B preventive service. For 2026, Medicare also pays it with home and residence visits, 99341 to 99350.
Prolonged time is where Medicare and commercial payers split. Medicare does not recognize CPT's 99417 and pays G2212 instead, which starts 15 minutes past the maximum time CMS assigns to the visit, not past the minimum. Commercial plans that follow CPT usually want 99417.
Source: CMS CY2025 PFS final rule fact sheet · CMS MM14315 · Medicare Claims Processing Manual, chapter 12
Referrals
Primary care orders much of the care that specialists bill for, and the referring note often decides whether those claims pay.
A positive stool test is the common case. For Medicare, the follow-on colonoscopy is still a screening service, and how the gastroenterologist codes it decides whether your patient gets a bill. The coding is set out in our guide to gastroenterology billing.
Diabetic foot care is the other. Medicare covers routine foot care only for patients with a qualifying systemic condition and documented findings, and for some diagnoses the patient must also be under the active care of the physician managing that condition, which is often your practice. The findings and modifiers involved are covered under podiatry billing.
Comparison
A process comparison, not a record of a particular practice and not a promise of outcome. It shows what changes in how claims are handled.
| Area | Before | With Quilven |
|---|---|---|
| Same-day visits | Problems handled during the physical billed as preventive only, or modifier 25 added by default. | Problem work billed separately only when the note supports it, with the modifier on the problem visit line. |
| Wellness timing | AWVs booked without checking the last IPPE or AWV date, then denied. | Eligibility dates checked before the visit is scheduled. |
| Transitional care | Discharges found weeks later, after the two-day contact window closed. | Discharge lists worked daily, with contact attempts and visit dates documented. |
| Care management | Consent and minutes kept in spreadsheets, and months that met the threshold never billed. | Consent on file before the first claim, and minutes reconciled to the code each month. |
| Add-ons | G2211 missing on follow-up visits, and prolonged time sent to Medicare as 99417. | G2211 applied by payer and visit type, and prolonged time coded to each payer's rule. |
| Rejections | Rejected claims sit in the clearinghouse queue until the filing window closes. | Rejections worked within four to five days, while the claim is still recoverable. |
Which of these applies to your claims is a question the audit answers. Request the audit.
Case study
One AR recovery engagement, at a family medicine practice in Minnesota. Shown for method. Individual results vary. One engagement is not a forecast.
We reviewed 245 claims. The rejection queue had no owner, and some claims in it had waited close to a year.
Billed charges in that queue came to roughly $40,000 to $50,000, none of it being worked.
Most of the damage started before the claim was built. Stale coverage, incorrect member IDs and skipped eligibility checks at the front desk caused 70% of the denials.
Not everything could be reopened. On most of the affected claims, a commercial payer's 90-day window had already passed with no proof of submission on file, so appeals were not possible.
What came back was about $5,500, paid on 50 to 55 claims, most of it within 45 to 50 working days.
In their words
What you have provided for me was a detailed of things that are going wrong that needed to change in our practice.
I appreciate that you did an audit and found out the root causes of a lot of my problems which are preventable.
I appreciate the professionalism, the courtesy, the knowledge.
After the audit the practice changed how it runs: eligibility verified before arrival, no more walk-ins, every patient checked the night before.
Pricing
Same pricing as every Quilven engagement, with nothing primary-care-specific. See how every Quilven service is priced.
12 to 15%
of the recovered amount
No fee on what is not recovered. Where a practice lands in the range depends on claim volume, age of the inventory, and payer mix.
3 to 5%
of collections by monthly volume
A $500 monthly minimum applies. The rate moves with monthly volume, not with headcount on your side.
$150 to $200
per payer application
$200 per application, or $150 each for 8 or more. Can be included in a custom package for billing clients. Payer and state fees are paid by the practice.
Fit
Outsourcing your billing does not require a system swap. We integrate with 30+ EHRs and practice management systems and work inside the one you already have. No data migration, no parallel system, no change to how your staff enters a charge or checks a patient in. If your team is trained on your current software, that training stays valid.
This matters because the usual objection to outsourced billing is that it turns into an implementation project. It does not here. Quilven is a managed service, not software. There is no proprietary platform you are asked to adopt and no license to renew, so the engagement can start on the claims you already have rather than after a build-out.
What you do get is visibility. Apex is our client dashboard, and it shows in real time:
Apex reads the work we are doing in your system. It is a window, not a replacement, so if the engagement ends your records and workflows are exactly where they were.
Company
Quilven is a managed revenue cycle service. Not software, not an EHR, and not a proprietary platform you have to adopt. We work inside the system your practice already uses, across 30+ integrations, with no data migration and no workflow change. Our clients are independent practices with 3 to 25+ providers.
Pricing is straightforward. AR recovery is 12 to 15 percent of the recovered amount. Medical billing is 3 to 5 percent of collections by monthly volume, with a $500 monthly minimum. Credentialing is $150 to $200 per payer application.
The entry point is a free RCM audit. It takes 48 hours and returns a line-by-line recoverable revenue estimate by payer, so the first thing you get from us is a diagnosis you can act on with or without us.
We lead with method and evidence rather than tenure. Quilven was founded in 2025 by Raief Shick. QUILVEN, LLC is registered in Wyoming, with its principal office at 1603 Capitol Ave, Cheyenne, WY 82001. Reach us at (202) 490-9406 or info@quilven.com.
Fit
Independent primary care and family medicine practices with 3 to 25+ providers, including groups with a Medicare-heavy panel or a care management program.
Internal medicine groups with hospital work or a large Medicare Advantage panel should also read about internal medicine billing.
It also fits practices whose biller has just left, or whose billing company submits claims but does not work the denials. See what to do first when a biller quits and how to check whether denials are being worked.
It is not for hospitals billing facility claims.
At a glance
FAQ
Sources
Checked 29 October 2026. Rules and published figures change, so confirm the current version before you rely on one.
Next step
The audit takes 48 hours and returns a line-by-line recoverable revenue estimate by payer, plus the repeating root causes behind your denials. We only need aging totals to begin. No patient data, no contract, no obligation to work with us afterward. If your aging is healthy we will tell you that.
Answer three questions below and book a line-by-line audit of your primary care claims.
Where is the money leaking right now?
Pick the one that hurts most. We start there.
How old is your oldest unpaid claim?
A round number is fine. We verify it in the audit.
How big is the practice?
Just you, or a group. Either is welcome.
Last bit — where do we send the report?
No patient data. We only need aging totals to start.
(202) 490-9406 · info@quilven.com · Book 15 minutes
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Analysts who work aged AR and appeals on a set cadence, by code, until each claim resolves.