Primary Care Exception Needs Expansion, AAFP Tells CMS

Change Would Better Fit Modern Training and Reduce Bureaucracy

October 14, 2019 01:22 pm News Staff

Vital training for medical residents, access to primary care and the patient-physician relationship would all be improved by a billing-code change the Academy this month called on CMS to consider.

[young physician visiting elderly patient]

In an Oct. 9 letter(4 page PDF) to CMS Administrator Seema Verma, M.P.H., the AAFP called for the agency to add 23 codes for certain teaching physician services to the agency's primary care exception rule. Updating the rule, which applies to outpatient visits performed by residents beyond their first six months of post-graduate training, would foster high-quality patient care by allowing residents to deliver important services without direct supervision, the Academy said.

It also would update federal policy to reflect the latest screening and preventive services that primary care physicians offer, noted the letter, which was signed by Board Chair John Cullen, M.D., of Valdez, Alaska.

The longstanding primary care exception codes(www.cms.gov) are 99201-99203 for new-patient evaluation and management services; 99211-99213 for established patient E/M services; and G0402, G0438 and G0439 for "welcome to Medicare" and annual wellness visits. The suffix "GE" is added to a billing code to indicate a full primary care exception, whereas "GC" indicates that the service was performed with the teaching physician present.

Story Highlights
  • The Academy recently called on CMS to consider adding 23 codes to the primary care exception rule.
  • This revision would allow important screening services and preventive care to be delivered in the residency setting, said the AAFP's Oct. 9 letter.
  • Patient assessment has changed in the two decades since the exception was established, and coding -- particularly for Level 4 visits that today are less complex -- should be brought up to date.

It's time to expand that list, the AAFP said.

Given the number of new screening protocols and important preventive care recommended by the U.S. Preventive Services Task Force(www.uspreventiveservicestaskforce.org) and offered by primary care physicians, "more can be done to promote and provide these services in the residency setting," the Academy wrote.

"After receiving appropriate training and supervision to assure demonstration of correct application of screening and preventive codes, CMS should allow residents to provide these services with indirect supervision under the primary care exception rules," the letter said. Progress in this area, the Academy added, would "enhance both the quality of the patient experience and the learning environment for the resident."

Likewise, the letter advised, patient assessment has changed in the two decades since the exception was established, and coding should be brought up to date.

Limiting the primary care exception to the teaching physician rule made sense in the mid-1990s, the Academy said, recalling an era when Level 4 Codes 99204 and 99214 denoted "complex visits often involving patients with acute or unstable chronic conditions requiring the teaching physician to personally examine and assess the patient to assure a high standard of care."

Today, however, Medicare patients with three or more chronic conditions routinely present for new and follow-up visits that do not involve diagnostic complexity beyond a resident physician's ability to provide high-quality care with indirect supervision, the letter said.

Over the same 20 years, medical training has moved toward competency-based assessment, with rigorous standards for supervision, the Academy said, citing the Accreditation Council for Graduate Medical Education's common program requirements.(www.acgme.org)  

"With these internal processes in place, we believe it is safe, appropriate and advantageous for CMS to include the 99204 and 99214 codes in the primary care exception," the letter said.

Additionally, the Academy advocated for the inclusion on the primary care exception list of the codes for chronic care management, transitional care management and home visits.

Transitional care management code 99495 includes a face-to-face visit with a clinician, "which we believe a resident physician can provide under the primary care exception," the Academy said. And chronic care management is mainly performed by clinical staff in support of the clinician, with face-to-face visits with a physician separately reportable.

Home visit codes, meanwhile, are indicative of the site of service rather than of medical decision-making and previous office visits already covered under the primary care exception. That minor difference, the Academy said, does not merit home visits' continued exclusion from the exception.

Among the other codes named in the Academy's letter are those covering depression and alcohol-misuse screenings, tobacco cessation counseling and advance-care planning.

The latter, the Academy said, "is a valuable service for patients that CMS has previously determined to be appropriately delivered through team-based care. A sufficiently trained resident should be considered a member of that care delivery team."

These additions, the Academy said, would reduce unnecessary bureaucracy without limiting supervision. One possible result: Preceptors could spend more time with resident physicians on complex and unstable patients, regardless of the code billed.

"Through annual rulemaking, we encourage CMS to review the accuracy and appropriateness of this list," the Academy wrote.