The Center for Medicare and Medicaid Services (CMS) has pushed for a multi-pronged strategy to increase investments in primary care to ensure not only their clinical but also their financial growth. CMS understands and acknowledges the value of primary care particularly in transitional and care coordination services by creating additional codes so Primary Care Physicians can get paid for the services they provide.

Annals of Internal Medicine

However, a recent study in the Annals of Internal Medicine has shown that Primary Care Physicians are missing out on as much as $200,000 a year by not utilizing Medicare’s prevention and care coordination billing codes as frequently as they should.

The study looked into the potential and actual billing for 19 prevention and 15 care coordination codes, which represented 13 categories of service stipulated in the Medicare Physician Fee Schedule (MPFS) from the years 2005 to 2020. These codes are designed to cover the different services that Primary Care Physicians often provide without being paid for them. In the same manner, the codes are supposed to entice Primary Care Physicians to offer services that highly benefit patients.

Primary Care Physicians are billing for only a small fraction of patients they treat.

The study used two kinds of estimates to compute the range of annual revenue that a full-time physician could potentially earn using the codes for every service category, depending on the specific type of practice and their patient population mix. The first one is for services already provided by the PCP but not being billed and the other calculates how much they could earn for the services if they billed only for half of their eligible patients.,

Primary Care Physicians and Medicare’s incentives

The study shows that Primary Care Physicians are not fully capitalizing on Medicare’s incentives despite having sufficient eligible patients. Here are some of the important findings:

• Medicare eligibility for each service ranged from 8% to 100%.

• The billing code median use was only 2.3% even if PCP use the appropriate prevention codes for 5% to 60.6% of their eligible patients.

• Around 22.5% of Medicare patients were recently hospitalized and qualify for Transitional Care Management (TCM). Out of these qualified patients, 43% sought primary care after they were discharged.

• For Chronic Care Management (CCM), 66% of patients were eligible, 33% for Behavioral Health Integration (BHI), and 10.5% qualified for cognitive assessment with care planning services. However, less than 3% of eligible patients participated in the said services.

If Primary Care Physicians have billed for all their preventive and care coordination services to just half of their eligible patients, they could earn annually as much as $124,435 for prevention and over $86,000 for coordination services.

Why are Primary Care Physicians not billing for their services?

Even with code-appropriate services, Primary Care Physicians are missing out on Medicare revenue simply because they are not billing for them as they should.

Here’s why Primary Care Physicians are not fully using Medicare’s prevention and care coordination codes:

1. Complex requirements to get paid

It takes too much time and requires a lot of effort to meet the requirements on eligibility, documentation, and the time and component of care for providers to bill for the codes and get reimbursed. Providers even believe that some requirements can be too prescriptive or even inappropriate. 

2. Upfront investment needed 

Even if doctors are well aware of the codes and the documentation requirements, they are hindered by the huge capital investment they need to set up the program including the personnel, technology, and infrastructure.

3. Too time-consuming

Others think that the time requirements may cause disruptions to their workflows and even hinder them from providing other essential services. To illustrate, in meeting the recommendations of the U.S. Preventive Services Task Force, providers may need more than eight hours a day. 

Furthermore, the authors of the said study reiterated that the additional codes for TCM, CCM, and PCM in the MPFS are designed to strengthen primary care in the country. However, the study has shown that this part is not yet fully realized. It might be better to utilize time-based billing as a payment method or global capitation which is more suited to the various activities provided by primary care.

How can Primary Care Physicians maximize revenues?

Even before the 2022 MPFS was fully implemented, primary care in 2021 posed a significant increase in net patient revenue per physician at full-time equivalent with 12.9% growth from the third to the fourth quarter according to Kaufman Hall’s physician flash report. Patient volume increased as many care services were deferred during the pandemic. However, this gain is countered by labor shortages and high cost of operational expenses due to inflation. 

Primary Care Physicians Medicare’s Incentives

Hence, Primary Care Physicians have all the more reason to capitalize on Medicare’s incentives to ensure their practice’s financial status, which could significantly impact the quality of care they provide.

To fully utilize Medicare’s prevention and care coordination codes, Primary Care Physicians need to think of a solution that enables them to navigate the complex requirements, avoid increased overhead, and improve their quality of care, particularly for their high-risk and high-cost patient population.

The most practical and profitable solution is to outsource essential services to a third-party vendor who has the technology, devices, personnel, and capabilities to fully implement these preventive and care coordinated services, namely, CCM, PCM, TCM, BHI, Annual Wellness Visits (AWV), and Remote Patient Monitoring (RPM).

Ascent Care Partners (ACP) offers virtual healthcare services as full services to help primary care practices realize much-deserved revenue and avoid the pitfalls of starting their own programs. We assist practices from patient enrollment to the preparation of billing charges and even as they scale up to fully maximize Medicare codes. With ACP, Primary Care Physicians will no longer miss out on Medicare revenue that helps them optimize their patient care while they see their practice grow financially.

We partner with the following providers:

• Primary Care Physicians
• Family Practice Physicians
• Internists
• Gerontologists
• Non-Interventional Cardiologists
• Endocrinologists
• Wound Care Doctors
• and other doctors