'System failure, not physician failure': PCPs lose thousands in revenue to coding, billing

Primary care physicians lose about $40,000 of revenue each year because they provide preventive services that they do not then code and bill, according to study findings published in Annals of Internal Medicine.

The Medicare Physician Fee Schedule continues to play a massive role in how PCPs are paid, “despite the proliferation of alternative payment models,” Sumit D. Agarwal, MD, MPH, of the division of general internal medicine and primary care at Brigham and Women’s Hospital and Harvard Medical School, and colleagues wrote.

Critical elements of continuous, comprehensive primary care are “poorly matched with visit-based payments,” the researchers added. Because of this, CMS has begun adding billing codes to the Medicare Physician Fee Schedule (MPFS) that recognize care that PCPs frequently provide without payment, like preventive counseling for weight loss or smoking cessation. But evidence suggests that physicians do not often use these billing codes.

“For instance, only 0.2% of Medicare beneficiaries had a claim for obesity counseling in 2015, and only 2.3% of eligible Medicare beneficiaries had a claim for chronic care management in 2016,” Agarwal and colleagues wrote.

In a recent modeling study, the researchers analyzed prevention and coordination codes that were added to the MPFS and approximated how much revenue PCPs potentially lose by not using them.

“Understanding the gap between services provided and use of billable codes could help inform Medicare's evolving strategy for optimizing payment of primary care services,” they wrote.

The researchers used survey data from across the United States and 2020 Medicare claims data to approximate the rates at which PCPs provided services and whether they were billed. They additionally used a validated microsimulation model of PCP practices to quantify lost revenue.

After analyzing 34 distinct codes representing 13 categories of service, the researchers found that PCPs forgo “considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients.”

Specifically, the median use of billing codes was only 2.3%, although the researchers found PCPs provided prevention and coordination services to more patients. For example, they provided prevention services to 5% to 60.6% of eligible patients.

In total, during 1 year, PCPs provided preventive services that were worth up to $40,187 in additional revenue — about 16% of a PCP’s annual salary, according to the researchers.

“Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care,” the researchers wrote.

Agarwal and colleagues estimated that if a PCP provided and billed all prevention services to just half of their eligible patients, they could add $124,435 to the practice’s annual revenue. For coordination services, they could add $86,082 in revenue.

“Our results suggest that having to navigate the eligibility, documentation, time, and component requirements of numerous separate codes may be too high of a hurdle to warrant the effort from PCPs to use those codes,” the researchers concluded, noting that billing requirements can be “detailed and require review of 500 or more page updates to the Medicare payment rules published annually in the Federal Register.”

In a related editorial, Davoren Chick, MD, senior vice president of medical education at ACP, wrote that it is “tempting to interpret underuse of new billing codes as a simple change management problem,” but “if the new codes truly financially rewarded primary care physicians for important underpaid services, we would not expect such a poor record of adoption.” “Nonadoption more likely results from the codes themselves,” Chick wrote.

Additionally, she noted that physicians likely engage in screening and counseling but their services may not be exactly provided in a “currently billable manner.”

“For example, a physician who extends an office visit to engage a patient in discussion about eating habits, exercise, goal setting, or weight loss strategies may not code for obesity counseling; the code cannot be used in combination with a routine evaluation and management visit, a routine preventive care visit, or a Medicare annual wellness visit,” Chick wrote. “To bill Medicare, a clinician must perform at least 15 minutes of separate counseling services and document implementation of a specific behavioral therapy framework. The code confers minimal payment for the time involved.”

To curb revenue loss, “we must empower ourselves with knowledge of coding rules for services we commonly provide,” Chick wrote.

“We must use knowledge not only to optimize current payment but also to advocate for change,” she added. “Widespread underuse of new preventive service and coordination of care codes reflects system failure, not physician failure.”

References:

• Agarwal S, et al. Ann Intern Med. 2022;doi:10.7326/M21-4770.
• Chick D. Ann Intern Med. 2022;doi:10.7326/M22-1897.