PCPs Miss Out on Payments for Prevention, Coordination

PCPs Miss Out on Payments for Prevention, Coordination


Primary care providers could add more than $100,000 to their incomes by billing more often for prevention and coordination of care services using Medicare codes, a new study shows.

According to the new research, primary care physicians used these codes for a median of only 2.3% of services provided to eligible patients.

“Investing in primary care is good for the health of patients, for achieving health equity, and for improving the value of health care spending, and yet the U.S. underinvests in primary care,” lead author Sumit D. Agarwal, MD, of Brigham and Women’s Hospital, Boston, said in an interview.

“One strategy to rectify this has been to add billing codes to the physician fee schedule for PCPs to use and thus raise primary care spending; Medicare has been activating new codes for the better part of 2 decades, and we wanted to investigate how successful this strategy of adding codes to the Medicare Physician Fee Schedule (MPFS) schedule has been to inform discussions on how best to finance primary care in the United States,” he said.

In a study published in Annals of Internal Medicine, Agarwal and colleagues reviewed nationally representative claims and survey data from 2019 and 2020. They analyzed 34 distinct prevention and coordination codes in 13 categories that have been added the MPFS since 2005. Of these, four involved coordination of care (cognitive impairment, behavioral health integration, chronic care management, and transitional care management). The other nine categories in prevention were wellness visits, advance care planning, shared decision making for lung cancer screening, obesity counseling, behavioral counseling for CVD, depression screening, alcohol misuse counseling, alcohol misuse screening, and smoking cessation counseling.

Overall, 8.8%-100% of older adult patients were eligible for preventive services. A range of patients (5.0%-60.6%) had codes for receiving services in their patient information.

“However, a much smaller fraction of eligible patients was billed for having received the service, ranging from less than 1% for alcohol misuse counseling or obesity counseling to 35.8% for wellness visits, with most below 10%,” the researchers wrote.

The median use of billing codes was 2.3% for eligible patients.

A PCP who provided and billed preventive services to half of all eligible patients could potentially increase revenues of $1,269 to $45,406 per code, with an annual revenue increase of $124,435 (interquartile range $30,654 to $226,813) for prevention services. Similarly, providing and billing coordination of care service to half of all eligible patients could increase revenue by $86,082 (IQR, $18,011 to $154,152).

“Importantly, all of these prevention and coordination codes involve decomposing the comprehensive care of a patient into component parts, each with multiple steps and checklists, which may be inconsistent with how PCPs practice and document care,” the researchers wrote in their discussion. “Unlike hospitals, primary care practices are typically unable to use departments of trained coders to maximize billing and ensure that documentation matches the requirements specified in billing rules,” they added.

The study findings were limited by several factors including the focus only on the Medicare segment of PCPs’ panels, which suggests conservative estimates of reimbursement, the researchers noted. Other limitations include response bias to the use of surveys, lack of survey data on specific billing requirements, and the potential underestimation of services by PCPs who delivered some, but not all, components of a service code.

However, the results reflect previous research to show the underutilization of prevention and coordination codes in primary care, and the need for ways to increase their use, the researchers said. “The discrepancies between service eligibility, provision of services regardless of billing, and actual billing suggest that attempting to codify each distinct activity done by a PCP in the MPFS may not be an effective strategy for supporting primary care,” they concluded.

Barriers to Code Use Persist for PCPs

“What surprised us was that there were many codes; we analyzed 34 in the paper in 13 distinct categories of services, and Medicare continues to add new primary care codes to the fee schedule,” Agarwal said in an interview. Also surprising, “take-up is low virtually across the board, and this isn’t for lack of eligibility,” he said. The low use of the codes “is not for lack of counseling patients on diet, drinking, exercise, smoking, or anything else for which these codes are meant to pay PCPs … The potential revenue from these codes in aggregate is huge,” Agarwal emphasized.

“My hope is not necessarily that physicians read this study and start using some or all of these codes more frequently,” said Agarwal. “It can be tempting to think of this as money left on the table, but it’s not; there are compliance, billing, and opportunity costs from using these codes,” he said. “For individual PCPs seeing individual patients for the breadth that is primary care, I’m not sure the juice is worth the squeeze,” he added. “My coauthors and I are all primary care physicians. We know from our research and first-hand that these codes can be cumbersome to use.” These codes also don’t reflect how PCPs practice, he said. “PCPs are not in the business of slicing and dicing a visit or patient to extract as much revenue as possible. The physician-patient interaction is more complex, and richer, than these codes imply. Instead, I hope our paper encourages Medicare and policymakers to take a harder look at other strategies for investing in primary care,” Agarwal added.

As for additional research, “Primary care spending is going in the wrong direction,” said Agarwal. “We need to figure out how best to finance primary care in the United States.”

Recent studies have examined the successes and limitations of the primary care medical home model, Medicare’s Comprehensive Primary Care Initiative, and primary care spending legislation, he said. “Our study is another piece of the puzzle: at least in its current form,” and the results suggest “that one-off codes were nice in theory but not in practice,” he noted.

New Codes Are Cumbersome

“It’s tempting to interpret underuse of new billing codes as a simple change management problem,” Davoren Chick, MD, chief learning officer of the American College of Physicians, wrote in an accompanying editorial. However, the underuse of codes for preventive service and coordination of care likely stems from the details of the codes, he said.

The new codes require the documentation of specific components and a minimum duration of services, he explained. “Codes that reward discrete service episodes disadvantage physicians who appropriately integrate preventive services within a continuous patient care relationship,” he added.

Chick presented an example of a primary care physician who would have to deliver intensive behavioral therapy for obesity in 15-minute episodes outside of a routine office visit to meet the billing criteria for current Medicare codes.

Chick called on clinicians to educate themselves on the coding rules for the services they provide “not only to optimize current payment but also to advocate for change.”

He concluded: “Widespread underuse of new preventive service and coordination of care codes reflects system failure, not physician failure. We must stand firm with this knowledge to demand increased payment for feasible, patient-centered primary care commensurate with its value in achieving better outcomes and lower costs.”

The study was supported by the National Institute on Aging of the National Institutes of Health. Agarwal and Chick had no financial conflicts to disclose.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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