Primary care docs question the value of some Medicare billing codes.
Primary care physicians aren’t using Medicare billing codes for prevention and care-coordination services, apparently deciding it’s not worth the bother.
Questions surrounding Medicare reimbursement and billing codes for primary care physicians (PCPs) were raised by a recent study published in “Annals of Internal Medicine.” Using national survey data, researchers from Brigham and Women’s Hospital and Harvard Medical School analyzed 34 distinct prevention and coordination codes, representing 13 distinct categories of services. They found that although services were provided to up to 60.6% of eligible patients, billing codes were only used at a median 2.3%. The authors concluded with proper and comprehensive coding, a single PCP could potentially add $124,435 in prevention services and $86,082 in coordination services to their practice’s annual revenue. They also estimated each PCP provided preventive services worth up to $40,187 in additional revenue.
But some question how much they’re really losing.
Money on the table?
“It can be tempting to think of this as money left on the table, but it’s not,” research author Sumit Agarwal, M.D., MPH, told Repertoire in an email exchange. “There are compliance, billing, and opportunity costs from using these codes,” which are supposed to address prevention and care-coordination services.
Prevention codes are those that cover services – usually some sort of counseling – provided during visits, and coordination codes are those that pay for services provided between visits (in other words, outside of traditional face-to-face office visits), says Dr. Agarwal. The researchers included wellness visits (the Welcome to Medicare visit and Annual Wellness visit) within the prevention codes category since wellness visits encompass a set of preventive services.
“It turns out that Medicare has been activating new codes for the better part of two decades, and we wanted to investigate how successful this strategy of adding codes to the fee schedule has been to inform discussions on how best to finance primary care in the U.S.,” he says.
They found that take-up remains low for all. “And this isn’t for lack of eligibility. And it’s also not for lack of counseling patients on diet, drinking, exercise, smoking or anything else for which these codes are meant to pay PCPs.
“A major reason these codes are underutilized is that they 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,” he says. What’s more, “the amount of reimbursement the typical primary care practice receives from [evaluation and management, or E&M] codes undoubtedly outweighs the amount of revenue lost from prevention and coordination services.
“This is partly why these new codes have been such a failure in terms of take-up. It’s a losing proposition for a practice when you combine (1) the complexity and costs of having to navigate the eligibility, documentation, time, and component requirements of numerous separate codes with (2) their relatively low reimbursement and (3) the likely possibility that they would displace the delivery of other necessary services.”
Regarding coordination codes, physicians and practice managers may be reluctant or unable to make the upfront financial investment required to use them, says Dr. Agarwal. “Prior to realizing any additional revenue, these codes could require practices to invest substantial resources (e.g., hiring nonphysician staff) to support the delivery of these services, meet the many requirements for billing these codes, and ensure compliance. Second, the coordination codes are subject to the deductible and 20% coinsurance requirements under Medicare Part B. Patients without supplemental insurance may be reluctant to incur new out-of-pocket spending, and physicians may find discussions about the cost of these services to be uncomfortable or find it difficult to offer these services to just the subset of patients who are able or willing to pay.
“For most PCPs and most of these codes, I suspect the juice in terms of higher revenue isn’t worth the squeeze in terms of costs from learning and implementing these codes.”
Learn about codes
Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS has a different perspective. She is chief product officer and Approved Instructor for AAPC, an education and credentialing organization for medical coders, billers, auditors, practice managers and others.
“We have seen practices be successful in implementing these codes,” she says, referring to the prevention and care-coordination codes. “I agree it is challenging, but if providers are providing the care anyway, why not capture it and get reimbursed for it?”
Prevention and care-coordination services are often provided in addition to other E/M services and were created to report the distinctness of the service, she says. For example, Code 99406 – “Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes” – has a reimbursement rate of $15.57 in the office setting. “If the provider is spending three to 10 minutes discussing smoking cessation to improve the patient’s overall health, that is additional revenue they are entitled to.
“If they don’t think the patient will benefit from this type of care, then they should not perform the service.” But in many instances, providers are performing services but failing to understand what is required to document and code them.
Education about coding on the part of primary care physicians is helpful, says Jimenez. “What is more helpful is obtaining the tools to operationalize the implementation of these codes. Having access to documentation templates to capture the appropriate information would be extremely helpful for providers. Providers have limited time for education, so you need to make sure it is to the point. Our approach at AAPC for provider education is to focus on the clinical concepts that align with how they are treating their patients. If they document the clinical care provided, it should support the codes that are being billed.”
To do so, “providers need competent staff to provide them the administrative support needed to have a healthy revenue cycle,” she adds.
Davoren Chick, M.D., chief learning officer for the American College of Physicians, believes physicians “can and should learn coding guidance that is appropriate to their most commonly provided services,” she told Repertoire in an email. Dr. Chick wrote an editorial in “Annals of Internal Medicine” accompanying the research by Dr. Agarwal and colleagues titled “Medicare Codes for Primary Care: Expansions with Limitations.”
The ACP online coding hub houses the College’s “Coding for Clinicians” subscription series, with physician-to-physician coding information organized by clinical topics, she says. The teaching content provides case-based examples, interactive content, and formats that are responsive to handheld devices. The hub also provides video learning, downloadable tools, and advocacy information.
Payment reform needed
As important as coding education is, “we need a payment system that rewards longitudinal primary care, not single encounters that are separately coded and billed,” says Dr. Chick. ACP continues to advocate for payment reform, as described in its recent position paper, “Reforming Physician Payments to Achieve Greater Equity and Value in Health Care: A Position Paper of the American College of Physicians,” published in Annals of Internal Medicine in June 2022, she adds.
Says Dr. Agarwal, “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, and primary care spending is even going in the wrong direction. We need to figure out how best to finance primary care in the U.S. … At least in its current form, one-off codes were nice in theory but not in practice.
“My hope is not necessarily just that physicians read this study and start using some or all of these codes more,” he says. “I hope our paper encourages Medicare and policymakers to take a harder look at other strategies for investing in primary care. There may not be any big changes on the near horizon, but my sense is that [the Centers for Medicare & Medicaid Services] and other stakeholders are actively interested in figuring out how best to pay for primary care.”
The Innovation Center at CMS, for example, has been experimenting with ways to finance primary care, including the Comprehensive Primary Care Plus model, and more recently, the Direct Contracting and Primary Care First models, says Dr. Agarwal. “Furthermore, it remains to be seen how the recent changes to the E&M codes have affected primary care spending.
“In the Discussion section of our paper, we talk about time-based billing, monthly non–visit-based care management fees, and capitation. As alternatives to the underused one-off codes that try to slice-and-dice what PCPs do … these alternatives are worthy of rigorous evaluation.”
References:
The Underuse of Medicare’s Prevention and Coordination Codes in Primary Care, Annals of Internal Medicine, https://www.acpjournals.org/doi/10.7326/M21-4770
Medicare Codes for Primary Care: Expansions with Limitations, Annals of Internal Medicine, https://www.acpjournals.org/doi/10.7326/M22-1897
Reforming Physician Payments to Achieve Greater Equity and Value in Health Care: A Position Paper of the American College of Physicians, https://www.acpjournals.org/doi/10.7326/M21-4484