Impact of Primary Care Exception Expansion on Family Medicine Resident Billing During the COVID-19 Pandemic

Abstract

Background and Objectives: The Medicare Primary Care Exception (PCE) permits indirect supervision of residents performing lower-complexity visits in primary care settings. During the COVID-19 pandemic, Medicare expanded the PCE to all patient visits regardless of complexity. This study investigates how PCE expansion changed resident billing practices at a family medicine residency during calendar year 2020. We hypothesized that residents not constrained by the PCE would bill more high-level visits. Methods: We queried billing codes from attendings’ and residents’ established evaluation and management visits associated with the University of Washington Family Medicine Residency (UWFMR) from January to December 2020. We used χ2 tests to compare resident and attending physicians’ use of low/moderate and high-level codes by quarter. Results: Resident high-complexity code use increased after PCE expansion in Q4 (odds ratio [OR] 3.50 [2.34-5.23]) compared to Q1. No change was observed among attending physicians (OR 1.05 [0.86-1.28]). Resident and attending billing patterns became more similar following PCE expansion. Conclusions: With the PCE expansion, senior family medicine resident physicians at UWFMR used higher-complexity billing codes at a rate approximating that of attending physicians. The findings of this study have implications regarding the financial well-being and sustainability of primary care residency training and raise a relevant policy question about whether the PCE expansion should persist. More research is needed to determine whether these findings were replicated in other primary care residency practices, the impact on resident education, and the impact on patient outcomes.