BACKGROUND AND PURPOSE:

• The Centers for Medicare & Medicaid Services (CMS) have added billing codes to the Medicare Physician Fee Schedule (MPFS) that reimburse for primary care activities (e.g., weight loss counseling)
  • The adoption of these billing codes has been minimal
• Agarwal et al. (Annals of Internal Medicine, 2022) examined the potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS

METHODS:

• Cross-sectional and modeling study
• Population
  • Medicare patients in nationally representative claims and survey data
• Study design
  • Prevention codes derived from Medicare’s suite of preventive services with zero patient cost sharing
  • Examples would include those services with a Grade A or B USPSTF recommendation
  • Coordination codes referred to providing a written, comprehensive care plan and/or providing care outside of traditional in person visits
• Primary outcome
  • Frequency of use of billing codes representing prevention and coordination services
  • Estimated Medicare revenue

RESULTS:

• Range of eligibility among Medicare patients for each service with the potential for billing: 8.8% to 100%
  • Median use of billing codes among eligible patients: 2.3%
• PCPs provided code-appropriate services to more patients than were billed
  • e.g., for preventative services: to 5.0 to 60.6% of patients eligible
• If a PCP provided and billed all prevention and coordination services to half of all eligible patients, they would add to their practice’s annual revenue
  • For preventative services: $124,435 (IQR, 30,654 to $226,813)
  • For coordination services: $86,082 (IQR, 18,011 to $154,152)

CONCLUSION:

• Despite the ability to bill for preventative services, PCPs forgo revenue due to poor uptake of billing codes for prevention and coordination services
• The authors state

Counseling for obesity, smoking, and cardiovascular disease, for example, seemed to occur much more frequently per survey data than billing claims would suggest

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

Learn More – Primary Sources:

The Underuse of Medicare’s Prevention and Coordination Codes in Primary Care

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