Why primary care doctors are leaving revenue on the table

Study finds greater use of prevention, care coordination codes could bolster practices' bottom lines

Primary care physicians (PCPs) could be foregoing more than $200,000 annually by not billing Medicare’s prevention and care coordination billing codes as often as they could, according to results of a new study in Annals of Internal Medicine.

The authors analyzed the potential and actual use of 19 prevention and 15 care coordination codes from 2005 to 2020, representing 13 categories of service in the Medicare Physician Fee Schedule. The codes, they note, “attempt to recognize various services that PCPs frequently provide without payment while also encouraging PCPs to deliver services believed to be beneficial to patients.”

In 2019, Medicare paid PCPs $1.2 billion for prevention services and $383 million for care coordination services, in addition to $7.1 billion reimbursed for standard evaluation and management services.

They used two types of estimates to calculate the range of annual revenue a full-time doctor could earn from the codes within each service category, depending on the specific practice type and patient mix: one for services already performed by the PCP but not billed, and one as if they had provided and billed the services to half of all patients who were eligible for them.

The authors found that physicians were providing services represented by prevention codes to between 5% and 60.6% of eligible patients annually, but were billing only small fractions of patients receiving the services. About 22.5% of Medicare beneficiaries had a hospitalization that made them eligible for transitional care management services, of whom 43% were seen in primary care after discharge.

Similarly, 66% of beneficiaries were eligible for chronic care management services, about 33% for behavioral health integration services and 10.5% for cognitive assessment with care planning services. But less than 3% of eligible patients had a claim for any of these services., according to the study.

The authors say that if a PCP provided and billed all preventive or coordination services to even half of all their eligible patients, that doctor could add $124,435 for prevention services and just over $86,000 annually to a practice’s revenue.

The authors suggest several reasons why physicians do not bill transitional and care coordination codes more frequently. One is the amount of time and effort required to meet the eligibility, documentation, time and component requirements needed to get paid for the codes.

In addition, even if doctors and practice managers knew the code documentation requirements perfectly, they might be reluctant or unable to make the upfront investment needed to use them, believe certain requirements to be overly prescriptive or otherwise inappropriate, or be concerned that the codes’ time requirements could take time away from providing other necessary services. The authors cite a 2021 study estimating that it would take a physician more than eight hours per day to provide all the services recommended by the U.S. Preventive Services Task Force.

The authors say adding transitional and care management codes to the MPFS is one part of a multi-pronged CMS strategy for increasing the nation’s investment in primary care. But the study shows this part hasn’t worked, they add, and payment methods such as time-based billing and partial or global capitation might better cover the varied activities included in primary care.