Let’s be honest – medical billing can feel like learning a whole new language. As an internal medicine provider, you’re focused on patient care, not memorizing code numbers. But those little five-digit CPT codes for internal medicine? They’re the key to getting paid for the important work you do every day.
Think of this as your friendly cheat sheet to the most common codes you’ll use in practice – no jargon, just clear explanations you can actually use.
Guidance CPT Codes in Internal Medicine
CPT (Current Procedural Terminology) codes are medical codes used to describe services provided by physicians. these cpt codes for internal medicine typically fall into three categories:
- Evaluation and Management (E/M) Codes – Office visits, hospital care, and consultations
- Preventive Medicine Codes – Annual physicals and wellness exams
- Procedure Codes – Minor in-office procedures (e.g., injections, EKGs)
Let’s explore each category in detail.
1. Evaluation and Management Codes
E/M codes are the backbone of internal medicine billing. The level of service (1-5) depends on:
✔ History taken (problem-focused vs. comprehensive)
✔ Exam performed (limited vs. detailed)
✔ Medical decision-making complexity (straightforward vs. high-risk)
Office Visits (Outpatient)
| CPT Code | Description | Typical Use Case |
|---|---|---|
| 99202-99205 | New patient visit (Level 1-5) | First-time patient with new concerns |
| 99211-99215 | Established patient visit (Level 1-5) | Follow-up for diabetes, hypertension, etc. |
Example:
- 99214 (Moderate complexity): A 45-year-old with uncontrolled hypertension needing medication adjustment.
Hospital Visits (Inpatient)
| CPT Code | Description |
|---|---|
| 99221-99223 | Initial hospital care |
| 99231-99233 | Subsequent hospital visits |
Example:
- 99232 (Subsequent visit): Daily rounding on a patient admitted for pneumonia.
2. Preventive Medicine Codes
These cover annual physicals and wellness visits, which are crucial in internal medicine.
| CPT Code | Description |
|---|---|
| 99381-99387 | New patient preventive visit (by age) |
| 99391-99397 | Established patient preventive visit (by age) |
Example:
- 99396 (Established patient, 40-64 years): Annual wellness exam with screening labs.
Important Note:
- Medicare uses G0402, G0438, G0439 for Annual Wellness Visits (AWV).
- Do not report preventive and problem-focused visits together unless medically necessary (use modifier -25 if separate).
3. Common Procedure Codes in Internal Medicine
Internal medicine providers often perform minor procedures in-office:
| CPT Code | Description |
|---|---|
| 93000 | Electrocardiogram (EKG) |
| 90630 | Flu vaccine |
| 96372 | Therapeutic injection (e.g., B12, Toradol) |
| 87880 | Rapid strep test |
Example:
- 96372 + J1030 (Injection + Dexamethasone): Administering a steroid shot for allergic reaction.
Common Billing Mistakes in Internal Medicine
🚫 Using the wrong E/M level (Undercoding or overcoding)
🚫 Bundling preventive and sick visits incorrectly (Missing modifier -25)
🚫 Not documenting medical necessity (Leads to denials)
🚫 Using outdated codes (e.g., Medicare AWV codes vs. 9939X)
An experienced Internal Medicine Billing Services team can help avoid these costly errors.
Tips for Accurate CPT Coding
- Document thoroughly – Note history, exam, and medical decision-making.
- Verify insurance rules – Medicare vs. private payers have different requirements.
- Use modifiers correctly (e.g., -25 for separate E/M service, -59 for distinct procedures).
- Stay updated on coding changes – CMS and AMA revise codes annually.
Final Thoughts
Selection of right CPT codes for internal medicine ensures proper reimbursement and reduces claim denials. Accurate coding is essential because internal medicine includes multiple medical services, including preventive care and chronic care.
Need help with internal medicine billing? Our experts ensure clean claims and maximum reimbursements—contact us today!
