Medicare’s 2025 Physician Fee Schedule (PFS) is changing the way preventive services are billed. Yes, these updates aim to enhance patient care, but they also bring new complexities. Errors can trigger considerable financial setbacks—from claim denials to audit risks.
Larger clinics with in-house billing teams may be able to easily manage the updates. But what about practices with limited staff? For these smaller practices, navigating preventive services billing while effectively dodging claim denials can be overwhelming.
That’s why many practices are turning to outsourced billing services: to stay compliant, reduce administrative strain, and protect their bottom line. This guide breaks down what you need to know to bill preventive care services correctly, avoid costly mistakes, and keep your practice financially secure. Let’s dive in.
Worried About the 2025 Medicare Regulations?
Discover the Benefits of Outsourced Billing
Understanding Cost-Sharing Policies
Under Medicare Part B, preventive vaccines for influenza, pneumonia, hepatitis B, and COVID-19 are fully covered with no patient cost-sharing, ensuring that beneficiaries receive essential immunizations without financial barriers.
Also, colorectal cancer (CRC) screening coverage has been expanded. The 2025 updates now classify a follow-on colonoscopy after a positive Medicare-covered, blood-based biomarker test as part of a complete CRC screening, meaning patients will no longer face cost-sharing for this procedure.
This move is an important step toward reducing financial hurdles that would discourage patients from completing health screenings.
Meeting Your Medicare Billing Requirements
To ensure compliance and avoid billing issues:
- Verify patient eligibility before preventive services, especially for Medicare Advantage patients.
- Explain to the patients the cost-sharing exemptions for vaccines and CRC screenings under Part B.
- Apply HCPCS codes and modifiers that reflect updated cost-sharing policies.
Industry Hack:
Opting for 5 Star Billing Services can greatly benefit your clinic. Our billing specialists can assist in reminding patients about Medicare cost-sharing policies and answer their questions without the additional expenses associated with internal training.
Get a Custom Quote Now at 1-480-999-0180!
Utilize Appropriate Billing Codes
To prevent claim denials and remain compliant with 2025 Medicare regulations, clinicians should follow these essential billing updates:
Initial Preventive Physical Examination
G0402 (Initial exam) and G0403–G0405 (Electrocardiogram)
Patients new to Medicare Part B may avail of an initial preventive physical exam (IPPE) at no charge. This one-time exam includes:
- Checking the patient’s medical and social history
- Explaining preventive services
- Completing required screenings
Your Action Plan:
- Record all screenings and preventive education provided during the IPPE to avoid claim denials.
- Confirm that the patient is within 12 months of enrolling in Part B and that the IPPE has not been previously billed.
- Partner with professional billing services to navigate coding complexities and ensure that documentation reflects an individualized approach, lowering the risk of denials or rejections.
Annual Wellness Visits
G0438 (Initial) & G0439 (Subsequent)
Annual wellness visits (AWVs) involve the creation of a personalized prevention plan according to a health risk assessment. Payers are particular about the specificity of prevention plans and may scrutinize claims if the documentation is too generic or lacks clear, patient-specific action steps, including referrals and provider coordination.
Your Action Plan:
- Use structured documentation templates to ensure each visit includes personalized recommendations, risk assessments, and follow-ups.
- Assign roles within your staff to efficiently handle risk assessments, referrals, and compliance checks efficiently, or better yet, employ expert billing services to get support for this critical task.
- Use your electronic health record (EHR) to set up automatic alerts to track AWV eligibility and required documentation, reducing missed billing opportunities.
- Regularly review AWV claim denials and adjust documentation workflows to comply with Medicare’s evolving requirements.
Preventive Vaccine Administration
G0012 (Pre-exposure prophylaxis for HIV prevention); G0011 & G0013 (Counseling)
Starting July 1, 2025, rural health clinics and federally qualified health centers can bill for Part B preventive vaccine administration at the time of service. Providers can also continue using HCPCS code M0201 for in-home vaccine administration.
As stated above, Medicare Part B fully covers preventive vaccines for influenza, pneumonia, hepatitis B, and COVID-19. Additionally, hepatitis B vaccine coverage will expand to all patients who haven’t completed a full vaccination series or have an unknown vaccination history.
Your Action Plan:
- Ensure your EHR and billing software reflect new vaccine administration codes and payment structures before July 2025.
- Educate your team about billing to significantly boost the success rates of vaccine administration claims.
- Maintain accurate patient vaccination history to comply with expanded hepatitis B coverage and avoid duplicate billing issues.
- Work with outsourced billing experts to keep up with evolving preventive vaccine billing requirements while ramping up reimbursements.
Implement Documentation Practices
The same situation unfolds every year: A new Medicare update rolls in, and suddenly, staff and clinicians scramble to adjust. With little time to prepare, billing teams rush to process claims—only to see delays, denials, and compliance issues pile up.
Why? Inaccurate documentation, missed eligibility verification, and unclear service descriptions.
How Your Clinic Can Stay Ahead
- Record patient Medicare eligibility and confirm compliance with preventive service frequency guidelines.
- Use templates to ensure preventive services are consistently documented with required details.
- Maintain detailed records of patients’ adherence to frequency limits to prevent billing errors.
- Implement routine documentation reviews to catch missing details before claims are submitted.
- Discuss your documentation needs with a specialized billing team that can assist your clinic in preventing claim denials and meeting compliance requirements.
Preventive Services Billing—Done Right
Medicare’s Physician Fee Schedule can catch you off guard, but only if you’re unprepared.
Stay ahead by maintaining proper documentation, applying precise coding, and partnering with trusted expert billers. This strategy ensures your practice adapts to new Medicare billing rules while reducing administrative burdens.
With 5 Star Billing Services’ expert support handling the complexities, your team can focus on what truly matters: delivering high-quality preventive care that pays off in the future.