The General Practice Billing Cycle
General practice generates the highest claim volume per physician of any specialty. A busy general practitioner sees 20 to 30 patients per day, creating 20 to 30 claims daily, or 400 to 600 claims per month per physician. At an average reimbursement of $90 to $120 per visit, a single general practitioner generates $36,000 to $72,000 in monthly charges. The billing workflow must be designed for speed, consistency, and minimal manual intervention because the per-claim value does not justify extensive individual claim review.
Step 1: Patient Registration and Eligibility Verification
Verify insurance eligibility before every visit, even for established patients. Insurance changes (new employer, Medicaid renewal, Medicare enrollment) happen without patient notification. Run an automated eligibility check through the practice management system at least 48 hours before scheduled appointments. For walk-in or same-day appointments, run eligibility at check-in. Capture copay amounts, deductible status, and coinsurance percentages. Collect copays at check-in before the visit occurs. Practices that collect copays at check-in collect 95% of copay revenue; those that bill copays after the visit collect only 60% to 70%.
Step 2: Encounter Documentation and Code Selection
The physician or provider completes the encounter documentation in the EHR and selects the E/M level. Under the 2021 guidelines, the documentation must support the medical decision making complexity or time claimed. For MDM-based coding, document the number and complexity of problems addressed, data reviewed or ordered (labs, imaging, consultations), and the risk level of the management options. For time-based coding, document the total time including all same-day non-face-to-face activities. The EHR should prompt the provider to select the E/M level and display the MDM or time criteria for the selected level as a decision support tool.
Step 3: Charge Capture and Coding Review
Charge capture occurs when the provider closes the encounter and the charges flow to the billing queue. A coding review at this step catches errors before claim submission. Common errors in general practice: selecting 99213 when the documentation supports 99214 (undercoding, the most common revenue leak), failing to bill modifier 25 when an E/M and procedure are performed on the same day, omitting CCM charges for eligible patients, and using an unspecified ICD-10 code when a more specific code is available. A designated coder or billing specialist should review 100% of charges before claim submission, or at minimum, review all new patient visits and all claims above 99214.
Step 4: Claim Submission
Submit claims electronically within 24 hours of the encounter. The claim must include: provider NPI, place of service (11 for office), CPT code with any modifiers, up to 12 ICD-10 diagnosis codes linked to the appropriate CPT code, the date of service, and patient demographic and insurance information. For general practice, the most common place of service is 11 (office), but telemedicine visits use POS 02 (telehealth, other than patient home) or POS 10 (telehealth, patient home). Using the wrong POS code for telemedicine results in reimbursement at the wrong rate or outright denial.
Step 5: Payment Posting and Reconciliation
Post payments from electronic remittance advice (ERA) files within 48 hours of receipt. For general practice, automated payment posting handles 85% to 90% of payments without manual intervention. The remaining 10% to 15% require manual review for: partial payments (deductible application, coinsurance calculation), contractual adjustment verification, and denial or rejection posting. Reconcile posted payments against the fee schedule weekly. If a payer consistently pays below the contracted rate for a specific code, investigate whether the contract rate changed or whether the payer is applying an incorrect fee schedule.
Step 6: Patient Billing and Collections
After insurance adjudication, bill the patient for their responsibility (deductible, coinsurance, non-covered services). Patient statements should be clear, showing the service date, description, insurance payment, and patient balance. Send the first statement within 7 days of insurance adjudication. Send a second statement at 30 days and a third at 60 days. Offer payment plans for balances above $200. Practices that offer online bill pay and patient portal payment options collect 15% to 20% more in patient balances than those relying solely on mailed statements. Consider credit card on file programs where the patient authorizes charging their card for balances after insurance processing.