Physicians lose tens of thousands of dollars in income annually by not coding and billing preventative services

Abstract: https://www.acpjournals.org/doi/10.7326/M21-4770

Abstract: https://www.acpjournals.org/doi/10.7326/M22-1897

URL goes live when the embargo lifts

A modeling study found that primary care physicians (PCPs) lost additional revenue worth up to $40,187 annually for preventive services that were provided but not coded and billed. The study is published in Annals of Internal Medicine.

The physician fee schedule plays a dominant role in how primary care and other physicians are paid. However, core features of primary care—first-contact care that is continuous, comprehensive, and coordinated—are poorly matched with visit-based payments. The Centers for Medicare and Medicaid Services (CMS) have made efforts to address this issue by adding billing codes for these aspects of primary care including preventive services, such as providing counseling for smoking cessation or weight loss, and for coordination services, such as providing transitional or chronic care management. Many of these codes have been characterized by low rates of adoption, suggesting that the codes are not being adequately used to perform their function of financing primary care activities.

 

Researchers from Brigham and Women’s Hospital and Harvard Medical School used national survey data to estimate the service eligibility rate and the rate at which PCPs provided each of the services to their older adult patients. The authors analyzed 34 distinct prevention and coordination codes, representing 13 distinct categories of services. They found that although services were provided to up to 60.6 percent of eligible patients, billing codes were only used at a median 2.3 percent. The authors estimate that a single PCP could add $124,435 in prevention services and $86,082 in coordination services to their practice’s annual revenue. They also estimate each PCP provided preventive services worth up to $40,187 in additional revenue.

 

According to the authors, the results suggest that having to navigate the eligibility, documentation, time, and component requirements of numerous separate codes may be too high of a hurdle to warrant the effort from PCPs to use prevention and coordination codes. They also note that these codes involve decomposing the care of a patient into parts with multiple steps and checklists, which may be inconsistent with how PCPs practice and document care.

 

For an embargoed PDF, please contact Angela Collom at [email protected]. To speak with the corresponding author, Sumit D. Agarwal, MD, MPH, please contact Sarah Sentman at [email protected]

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