Impact of the Primary Care Exception on Family Medicine Resident Coding

• Published in: Family medicine Vol. 48; no. 3; pp. 175 - 179
• Main Authors: Cawse-Lucas, Jeanne, Evans, David V, Ruiz, David R, Allcut, Elizabeth A, Andrilla, C Holly A, Thompson, Matthew, Norris, Thomas E
• Format: Journal Article
• Language: English
• Published: United States 01.03.2016
• Subjects: Clinical Coding - economics; Clinical Coding - methods; Family Practice - economics; Family Practice - education; Female; Health Care Surveys; Humans; Insurance, Health, Reimbursement - economics; Internship and Residency - economics; Male; Medicaid; Medicare; Primary Health Care - economics; United States

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. 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. 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. 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.