The Underuse of Medicare's Prevention and Coordination Codes in Primary Care : A Cross-Sectional and Modeling Study.

backgroundEfforts to better support primary care include the addition of primary care-focused billing codes to the Medicare Physician Fee Schedule (MPFS).

objectiveTo examine potential and actual use by primary care physicians (PCPs) of the prevention and coordination codes that have been added to the MPFS.

designCross-sectional and modeling study.

settingNationally representative claims and survey data.

participantsMedicare patients. MEASUREMENTS: Frequency of use and estimated Medicare revenue involving 34 billing codes representing prevention and coordination services for which PCPs could but do not necessarily bill.

resultsEligibility among Medicare patients for each service ranged from 8.8% to 100%. Among eligible patients, the median use of billing codes was 2.3%, even though PCPs provided code-appropriate services to more patients, for example, to 5.0% to 60.6% of patients eligible for prevention services. If a PCP provided and billed all prevention and coordination services to half of all eligible patients, the PCP could add to the practice's annual revenue $124 435 (interquartile range [IQR], $30 654 to $226 813) for prevention services and $86 082 (IQR, $18 011 to $154 152) for coordination services. LIMITATION: Service provision based on survey questions may not reflect all billing requirements; revenues do not incorporate the compliance, billing, and opportunity costs that may be incurred when using these codes.

conclusionPrimary care physicians forego considerable amounts of revenue because they infrequently use billing codes for prevention and coordination services despite having eligible patients and providing code-appropriate services to some of those patients. Therefore, creating additional billing codes for distinct activities in the MPFS may not be an effective strategy for supporting primary care. PRIMARY FUNDING SOURCE: National Institute on Aging.