Recent research leaves little doubt that primary care physicians aren't fully reimbursed for the patient care they already provide. Yet the debate persists: Does investing more up-front time into better mastering the coding process pay off sufficiently over the longer haul?
One recent study, which analyzed a total of 34 Medicare prevention and coordination codes, identified “large gaps” between how often primary care physicians could bill for services, such as smoking cessation, and how often they did. If a primary care physician billed for preventive services provided to just half of eligible patients, they could collect an additional $79,029 annually in revenue, not counting annual wellness visits, plus a similar amount, as much as $86,082, if they also billed for coordination services, according to the findings, published June 28 by Annals of Internal Medicine.
But billing for more primary care services is not as easy as it sounds, said Davoren Chick, MD, FACP, ACP's Chief Learning Officer and Senior Vice President for Medical Education, who wrote an accompanying editorial, also published in Annals. The challenges, she said, involve the complexity of stipulations to bill for a particular service amid a time-pressed visit that's already covering a range of medical issues.
For instance, a physician might devote the minimum of three minutes required to bill for providing smoking cessation counseling and then complete the related documentation, Dr. Chick said. If that adds at least five minutes to a patient visit, “that may not sound like a lot of time. But it creates a situation where to provide that service for all of your [smoking] patients, you're adding on as much as another hour to the day.”
The Annals study, which looked at the use of primary care billing codes in the Medicare Physician Fee Schedule, found that some services, such as counseling for obesity, smoking, and cardiovascular disease, were provided “much more frequently per survey data than billing claims would suggest.” For instance, 8.8% of older adults smoke and, of those, 60.6% reported receiving advice to quit, according to the findings. But only one-tenth of the 8.8% had a claim for smoking cessation counseling.
Federal officials have moved to try to better reimburse primary care physicians by adding new Medicare codes, but that hasn't yet proven to be effective, said Sumit Agarwal, MD, MPH, the study's lead author and a primary care physician at Brigham and Women's Hospital and a health policy researcher at Harvard Medical School in Boston.
In addition to the logistics involved in learning and complying with the new codes, Dr. Agarwal said, they often don't align with the integrated flow of a primary care visit. A typical visit, he said, might encompass a brief discussion about a patient's smoking and some related counseling along with a weight loss discussion and, if the patient is elderly, feedback on some questions about advance care planning.
“The sheer interaction with a patient is a lot more complex, nuanced, and richer than these codes imply,” said Dr. Agarwal, who supports the recent move toward other strategies, such as time-based billing, as a better way to reflect the care that a physician provides.
Dr. Agarwal acknowledged that he doesn't use many of the codes that he studied in his own practice. “I don't think the juice is worth the squeeze,” he said. His few exceptions include coding for annual wellness visits, transitional care management, and smoking cessation counseling.
Despite the complexity, Dr. Chick noted that physicians shouldn't give up but should instead be strategic by, for example, focusing on a few coding areas that align with the patient care they frequently provide. Dan Ostrovsky, MD, FACP, lead physician coding liaison in the department of pediatrics at Duke University School of Medicine in Durham, N.C., agreed that better reimbursement is within more physicians' grasps than they realize.
“There's definitely a lot of low-hanging fruit in areas where things are being missed,” said Dr. Ostrovsky, also an associate professor of internal medicine and pediatrics at Duke. “Often it's nothing that they [physicians] would really have to do differently, they just have to recognize it.”
As one example, Dr. Ostrovsky said that some recent changes in the American Medical Association (AMA) CPT (Current Procedural Terminology) guidelines, effective January 2021, enable outpatient physicians to get reimbursed for patient care that extends beyond the time spent in the exam room.
To start off, most office visits for established patients are at least 20 minutes, so they should be coded as a level 3 visit at a minimum, Dr. Ostrovsky said. He described a level 2 visit as “a rarity in this day and age of medicine.”
But the clock doesn't stop with that face-to-face time and includes all activities related to the patient's care, he said. Often a physician might need an additional 10 minutes to update the patient's medical record, which brings the time commitment total to 30 minutes, meeting the requirement for a level 4 visit, Dr. Ostrovsky said. If the physician spends 10 minutes more reviewing lab results and then discusses care coordination with a nurse, such as a home health referral, the total is 40 minutes, a level 5 visit. (These time cutoffs are somewhat longer for new patient visits.)
When coding is based on total time, it's important to remember that only the time spent on the same day as the patient visit counts, said Dr. Ostrovsky, who has created a coding tools website that offers information on guideline changes, time-based calculators, and other resources. Physicians are not required to document the time spent on each component, but rather report the total time spent across the course of the day, he said.
“They are asking you to provide an honest accurate time count in total time,” Dr. Ostrovsky said. “It's really up to the provider to recognize the time they spent and document it accurately.”
Moreover, a patient visit that doesn't qualify for higher reimbursement based on time alone might be able to capture a higher level of service based on the elements of medical decision making, Dr. Ostrovsky said.
Under the latest CPT guideline, physicians could code for a level 4 office visit if the patient presents with either two stable medical issues or one worsened or uncontrolled medical problem, and if one of two additional elements of medical decision making are met, Dr. Ostrovsky said. Those include the review of at least three data elements—such as reviewing labs, images, or notes from an outside clinician—or prescription drug management. Medication-related management could involve prescribing new medication, as well as making decisions to continue or discontinue current medications, he said.
Thus, a routine checkup with a patient who has well-controlled diabetes and hypertension, which includes medication management, might only require 20 minutes, level 3 based on time, and still be billed as a level 4 based on medical decision making, Dr. Ostrovsky said. The same coding could be applied if a patient with diabetes had a hemoglobin A1c result that didn't meet the target goal and the physician decided to step up their medication, he said.
Physicians also should watch out for new medical issues that crop up during a routine preventive visit and bill accordingly, said Margie Andreae, MD, a clinical professor of pediatrics and chief medical officer for revenue cycle billing and compliance at Michigan Medicine in Ann Arbor. It's a familiar scenario for physicians, she said. A 35-year-old patient might arrive for an annual physical with concerns about a new issue, such as a recently sprained ankle, she said. But since the physical was already scheduled, the patient had delayed seeking care until the appointment.
Under that scenario, physicians could and should bill two separate codes, Dr. Andreae said. “Some physicians aren't aware that they can do that,” she said. “Some just choose not to because they think it's extra work, which it is. But they are leaving money on the table.”
Physicians also should alert patients so they won't be surprised by an additional charge, Dr. Andreae said. Patients might anticipate that their annual physical would be covered in full under the Affordable Care Act and not realize that they could be billed separately for treatment of their ankle injury, she said.
“A lot of physicians aren't comfortable talking to patients about charging and payment,” Dr. Andreae said. “But I think they should. I don't think that the patient should be surprised.”
Another way to keep patients informed is to post policies in the office detailing what's covered in an annual visit and noting that any separate medical issue might be billed for separately or require a follow-up visit, Dr. Andreae said.
Dr. Andreae noted that the coding and billing process has become unnecessarily complex, as the AMA's CPT Editorial Panel continues to expand the number of codes and related requirements. Roughly 55 CPT codes have been created related to preventive and care coordination work that's not included in the office visit codes, 28 of them in the last five years, she said.
“Primary care physicians are overwhelmed,” Dr. Andreae said. “They don't get good training on coding. It takes them as much time to document and code the service as it did to see the patient.”
Transitional care, chronic care management, and other codes have been added in recent years as part of a “long-standing effort to try to capture some of the additional work that physicians do, particularly in the cognitive arena and with non-face-to-face work, which is a lot of work that physicians do in internal medicine and family medicine that doesn't get captured,” said Doug Leahy, MD, MACP, a general internal medicine physician who practices in a physician-owned primary care practice based in Knoxville, Tenn., and serves as the ACP representative on the AMA's RVS Update Committee (RUC), which advises Medicare on valuation of physicians' work.
Even so, Dr. Leahy didn't disagree with Dr. Andreae regarding some of the coding complexities. The goal is to ensure data integrity and “make sure that there's not abuse of the code,” he said. “I think over time we're continuing to refine that. A lot of the doctors feel like it encumbers them; they feel like they can't get through the hurdles. It's been a really difficult time implementing them [the codes].”
Despite the additional effort involved, the payoff could potentially improve patient care along with reimbursement, Dr. Leahy said. His own multiphysician practice, which is predominantly engaged in value-based contracts, has tried to complete as many Medicare wellness visits as feasible, he said, noting that the exams are one of the data points tracked through quality metrics.
To date, about 93% of Medicare patients at the practice have gotten an annual wellness exam, which has helped to flag issues related to social drivers of health, Dr. Leahy said. In 2021, the practice conducted 157,000 wellness exams that identified roughly 10,000 issues, among them housing difficulties, food access challenges, depression, and aggression in the home, enabling physicians to refer those patients to social workers to assist, he said.
By selecting a few codes to focus on, Dr. Chick said, physicians “can see the benefit of some revenue coming in.” But it might be worth their time to brush up on the latest coding changes, she said. ACP recently launched new self-guided coding education, called Coding for Clinicians. The subscription series includes 13 interactive modules eligible for CME/MOC, as well as video recordings of ACP physician coding lectures and webinars.
“It's difficult to necessarily know what you don't know,” Dr. Chick said. As one example, she said, “They [physicians] may essentially be doing chronic care management without getting appropriately paid for it.”
Physicians should strive to become more comfortable with subjective judgments, whether it's calculating the total time spent on a patient or assessing whether a medical issue is worsening, Dr. Ostrovsky said. They should use their discretion and document accordingly, he said.
“We are very quantitative people,” Dr. Ostrovsky said. “And qualitative things that make you have to choose, you tend to undervalue what you're doing, such as, ‘Oh, that's not a moderate problem—it's an easy problem.’”
To catch coding patterns in a practice, an office manager or billing staffer could be asked to conduct a review at day's end, Dr. Andreae said. They could review how many times clinicians documented giving an injection or providing depression screening, for example, and didn't bill for those services.
Physicians will sometimes say they don't regularly perform this kind of reconciliation because of staffing considerations, Dr. Andreae said. “Again, you have to look at your return on investment,” she said. “And you are going to get your return by dedicating some staff time to that work.”