Primary Care Coding Alert

Question: What’s the criteria for the Centers for Medicare & Medicaid Services (CMS) to recognize the resident primary care exception? What codes can I use to report their services?

Washington, D.C. Subscriber

Answer: The Medicare Learning Network (MLN) Guidelines for Teaching Physicians, Residents & Interns booklet says that CMS sometimes allows residents to perform certain low- and mid-level complexity evaluation and management (E/M) services in primary care centers without a teaching physician present — and pays Medicare Physician Fee Schedule (MPFS) rates — though the teaching physician must review the care.

MLN says: “When you select time-based office or outpatient E/M visit levels, you may include only the time you spend performing qualifying activities, including your presence with the residents performing those activities. Under the primary care exception, you can’t use time to select visit level. You may only use [medical decision making] MDM to select the E/M visit level.”

Caveat: Since May 12, 2023, teaching physicians may no longer bill for office or outpatient (O/O) E/M levels 4 or 5.

MLN says that appropriate codes can include established patient codes 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional) to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) and new patient codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) to 99203 (… 30 minutes must be met or exceeded.).

Remember, under the primary care exception, only MDM can be used to determine the E/M level.

Relevant HCPCS codes for the primary care exception include:

• G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment)
• G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit)
• G0439 (Annual wellness visit, includes a personalized prevention plan of service (PPS), subsequent visit)

Don’t forget to check with commercial carriers and follow their respective policies for reporting primary care services provided by residents.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC