https://immattersacp.org/weekly/archives/2022/06/28/1.htm

Primary care physicians missing out on reimbursement for preventive services

Physicians provided reimbursable prevention and coordination services to 5.0% to 60.6% of Medicare patients but billed for a much smaller fraction, ranging from less than 1% for alcohol misuse or obesity counseling to 35.8% for wellness visits, a study found.


Based on a recent modeling study, primary care physicians appear to be underutilizing codes for preventive services that, on average, could amount to $40,000 per year in lost revenue.

Researchers used national claims and survey data from 2019 and 2020 to estimate service eligibility and the rate at which physicians provided 34 distinct prevention and coordination codes, representing 13 distinct categories of services. Results were published June 28 by Annals of Internal Medicine.

Depending on the code, 8.8% to 100% of Medicare beneficiaries, or approximately 67 to 762 patients per physician panel, were eligible for specific preventive services, and physicians provided services represented by those codes to 5.0% to 60.6% of eligible patients annually. However, a much smaller fraction were billed, ranging from less than 1% for alcohol misuse or obesity counseling to 35.8% for wellness visits, with most rates below 10%. The authors calculated that if a doctor provided prevention and coordination services to half of all eligible patients and billed for them, this could add $124,435 (interquartile range [IQR], $30,654 to $226,813) for prevention services and $86,082 (IQR, $18,011 to $154,152) for coordination services annually to their practice's revenue. In addition, they estimated that each PCP was providing preventive services worth up to $40,187 annually in additional revenue.

The study highlighted smoking cessation as an example. Of Medicare patients, 8.8% are smokers, and 60.6% of smokers report having been counseled to quit by a clinician. That group works out to 5.3% of all Medicare patients in an average primary care physician's panel, but the service is only billed for 0.9% on average. At a payment level of $15.52 for brief counseling, physicians on average failed to collect $638 (IQR, $134 to $1,143) in annual revenue, the study showed.

Having to navigate the eligibility, documentation, time, and component requirements of numerous separate codes may be too high of a hurdle, the study authors wrote. They said that adding new codes to capture more aspects of primary care has not been successful.

“Ultimately, the breadth and depth of primary care may be more than what one-off codes can capture, and the requirements to bill for these myriad codes may discourage their use. Alternative strategies that could better and more flexibly cover all of the varied activities in primary care include time-based billing and partial or global capitation,” they wrote.

An accompanying editorial by Davoren Chick, MD, FACP, ACP's Chief Learning Officer, attributed the problem to the codes themselves. Codes that reward discreet services “disadvantage” physicians who integrate preventive services into their routine care, the editorial said. 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, which cannot be done at the same time as a routine evaluation and management visit, a routine preventive care visit, or a Medicare Annual Wellness Visit.

“Widespread underuse of new preventive service and coordination of care codes reflects system failure, not physician failure,” the editorial stated. “We must stand firm with this knowledge to demand increased payment for feasible, patient-centered primary care commensurate with its value in achieving better outcomes and lower costs.”