Impact of the Primary Care Exception on Family Medicine Resident Coding.

BACKGROUND AND OBJECTIVES: The Medicare Primary Care Exception (PCE) allows residents to see and bill for less-complex patients independently in the primary care setting, requiring attending physicians only to see patients for higher-level visits and complete physical exams in order to bill for them as such. Primary care residencies apply the PCE in various ways. We investigated the impact of the PCE on resident coding practices. METHODS: Family medicine residency directors in a five-state region completed a survey regarding interpretation and application of the PCE, including the number of established patient evaluation and management codes entered by residents and attending faculty at their institution. The percentage of high-level codes was compared between residencies using chi-square tests. RESULTS: We analyzed coding data for 125,016 visits from 337 residents and 172 faculty physicians in 15 of 18 eligible family medicine residencies. Among programs applying the PCE criteria to all patients, residents billed 86.7% low-mid complexity and 13.3% high-complexity visits. In programs that only applied the PCE to Medicare patients, residents billed 74.9% low-mid complexity visits and 25.2% high-complexity visits. Attending physicians coded more high-complexity visits at both types of programs. The estimated revenue loss over the 1,650 RRC-required outpatient visits was $2,558.66 per resident and $57,569.85 per year for the average residency in our sample. CONCLUSIONS: Residents at family medicine programs that apply the PCE to all patients bill significantly fewer high-complexity visits. This finding leads to compliance and regulatory concerns and suggests significant revenue loss. Further study is required to determine whether this discrepancy also reflects inaccuracy in coding.

Family medicine resident billing and lost revenue: a regional cross-sectional study.

BACKGROUND AND OBJECTIVES: The financial margins for primary care clinics and residencies are narrow. It is important that residents bill properly for educational and financial purposes as well as for compliance. This study compares resident and attending Evaluation and Management (E&M) coding from family medicine residency programs across a five-state region, with established billing benchmarks. METHODS: We collected established visit E&M codes for faculty and residents from a network of family medicine residencies in the Northwest United States over a 6-month period. Aggregated codes were compared to billing benchmarks from the Medical Group Management Association (MGMA) to estimate effects on revenue from these visits. RESULTS: We obtained coding data for 131,788 established problem-focused visits from 353 residents and 186 faculty physicians in 16 of 18 eligible family medicine residencies. Both residents and faculty billed lower numbers of high complexity codes than MGMA benchmarks. PGY-1s coded higher numbers of high complexity codes than PGY-3s. Annual estimated revenue loss was $481,654 for the programs overall. CONCLUSIONS: Residents do not bill established visits at the level of generally accepted benchmarks, which contributes to significant financial losses for programs and carries regulatory implications. The reasons for incorrect billing need to be established and interventions developed to overcome these barriers.