Introduced by: Douglas W. Harley, DO, FAAFP, and Sandra Snyder, DO, FAAFP
Whereas, under the primary care exception, in certain teaching hospital primary care centers, teaching physicians can bill certain services that residents provide independently without teaching physicians present, but the teaching physicians must review the care, and
Whereas, all Accreditation Council of Graduate Medical Education (ACGME)-accredited family residency programs are required to have resident supervision policies and guidelines to ensure patient safety and maximal education, while allowing for an incremental increase of autonomy and graduated levels of responsibility, and
Whereas, many state Medicaid and private insurances permit E/M billing of services that residents provide independently without teaching physicians present, including but not limited to 99214 office visits, new preventative visits 99381-99386, and established preventative visits 99391-99396; however, many health systems are now requiring blanket use the Medicare
Whereas Care Exception guidelines across all payers, and
Whereas, under the strict, payer agnostic interpretation of the Primary Care Exception guidelines, a resident physician may provide a new Medicare patient a full Welcome to Medicare exam with indirect supervision but must have supervision for the non-Medicare patient receiving their annual physical exam, setting up a two tiered health care training system, and therefore be it
Resolved, that the Ohio Academy of Family Physicians strongly encourages the American Academy of Family Physicians reengage with the Centers of Medicare and Medicaid Services to addend the E/M Services Primary Care Exception HCPCS codes guidance documentation to better reflect comparable approaches to resident supervision requirements across payers, and be it further
Resolved, that the American Academy of Family Physicians encourage the Centers for Medicare and Medicaid Services to specifically add E/M codes 99381-99386 and 99391-99396 to the Primary Care Exception guiding documents.
Fiscal Note: $0
Explain how this issue is in line with OAFP Policies and/or the Strategic Plan
Workforce Development and empowering members to thrive and be recognized by the value that family physicians bring to the healthcare infrastructure.
Existing Evidence
www.cms.gov/files/document/guidelines-teaching-physicians-interns-residents.pdf
Major institution legal departments including Cleveland clinic foundation and Mayo Clinic have deemed the guidance verbatim. Therefore meaning that patient’s presenting for annual physicals must have direct supervision with the preceptor going into the room to complete major portions of the visit. This same requirement does not exist for a welcome to Medicare physical which includes all of the same components as an annual physical but because the guidance documents exclude this code on the primary care exception billing a preceptor can indirectly supervise the resident allowing for increased autonomy based upon resident competency. The concern is the negative effect on building autonomy amongst our future family medicine residents going out into Ohio’s workforce.
As a residency core faculty member committed to the education of future family physicians and the delivery of high-quality patient care, I am deeply concerned about the lack of appropriate interpretation and application of the primary care exception (PCE) within family medicine residency programs as follows: the application of the Medicare Teaching Physician Rules to all payors and the restriction on the CPT codes that the PCE is applied to, specifically the lack of ability to apply PCE to Adult Physicals and Well Child Care. While the PCE is intended to facilitate billing for resident services under appropriate supervision, its misapplication undermines the core principles of residency education, patient-centered care, and faculty engagement. Outlined below are the significant negative impacts this issue has on residents, patients, and attending physicians within my own residency.
Impacts on Residents
The inappropriate application of the PCE may disrupt the educational process and compromise the autonomy and development of family medicine residents. Specifically:
1. Resident Autonomy on Patient Care: Residents are deprived of the opportunity to independently manage patient cases and make clinical decisions within a supervised environment, a critical component of their growth as competent physicians.
2. Decreased Individualized Resident Education Time: The administrative burden placed on attending physicians due to billing requirements reduces the time available for individualized resident education, thoughtful case review, and tailored feedback.
3. Decreased Resident Visit Numbers: Misapplication of the PCE often results in truncated resident clinic schedules due to increased time needs for attending billing physician participation. This decreases resident visit numbers and their exposure to diverse clinical scenarios and impairs their ability to develop competency in managing complex cases.
4. Diminished Quality Supervision in High Acuity Cases: When faculty are required to focus on administrative oversight rather than clinical supervision, residents may not receive the critical guidance needed during high-acuity or challenging patient encounters.
5. Decreased Time for Thoughtful Viewing and Direct Supervision: Effective resident education requires attending physicians to thoughtfully view video monitored patient cases and directly supervise resident decision-making. Misapplication of the PCE diminishes the time and focus needed for this essential educational process.
Impacts on Patients
The inappropriate use of the PCE may also negatively affect patient care, satisfaction, and continuity, jeopardizing the trust and confidence patients place in their resident physicians. Specifically:
1. Decreased Patient Satisfaction: Patients may feel disconnected or dissatisfied with their care experience due to the diminished involvement of their primary resident physician and the perceived over-involvement of attending physicians in routine visits, particularly adult Physicals and Well Child Care.
2. Decreased Patient Trust and Confidence in Resident Physicians: Patients may struggle to build rapport and trust with their resident physician if the attending physician assumes a disproportionate role in patient care due to billing requirements.
3. Increased Appointment Length Without Added Value: The administrative requirements imposed by the misapplication of the PCE often elongate appointment times without improving the quality of care delivered.
4. Increased Patient Confusion: Patients may not clearly understand who their physician is—resident or attending—leading to confusion and dissatisfaction, particularly in cases where continuity of care is disrupted.
5. Altered Continuity of Care: The inappropriate involvement of attending physicians can disrupt the continuity of care patients expect with their resident physician, undermining the relationship-building process that is central to family medicine.
Impacts on Attending Physicians
Finally, the misapplication of the PCE may significantly disrupt the role of attending physicians as educators and clinical supervisors, contributing to faculty burnout and increasing liability risks. Specifically:
1. Disrupts Precepting Sessions and Feedback: Attending physicians are forced to prioritize administrative oversight over meaningful precepting and feedback sessions, reducing their ability to focus on resident education.
2. Inability to Adequately Supervise Residents: The administrative demands associated with inappropriate application of the PCE may impair attending physicians’ ability to triage supervision based on the medical complexity of cases, leaving residents underserved in situations that require high-level guidance.
3. Faculty Burnout: The additional administrative burden placed on attending physicians leads to faculty burnout, as they are required to perform unnecessary supervisory tasks that neither improve patient care nor enhance resident education.
4. Increased Liability Risks: The inability to prioritize supervision based on medical necessity, rather than billing requirements, increases attending physicians’ liability risks, creating a precarious situation for faculty, residency programs, and healthcare systems alike.
The lack of appropriate interpretation and application of the primary care exception in the setting of adult Physicals and Well Child Care undermines the foundational goals of family medicine residency education and patient care. This diminishes resident autonomy, limits individualized education, and disrupts the continuity and quality and safety of patient care. Furthermore, it places undue administrative and supervisory burdens on attending physicians, contributing to burnout and liability risks.
I urge the OAFP to advocate for a more thoughtful and appropriate application of the primary care exception that prioritizes resident education, patient satisfaction, and attending physician engagement. Residency programs must be allowed to focus on their primary mission: training competent, compassionate family physicians who deliver high-value, patient-centered care. Any policies or practices that detract from this mission must be carefully reconsidered to ensure the long-term success of family medicine residency education and the health of the patients we serve.
As a current preceptor at the Cleveland Clinic Family Medicine residency, I fully support this resolution.
I fully support this resolution. The application of the PCE disrupts our educational process. During my resident continuity clinic, we see various patient cases with different degrees of acuity. Often, this requires attention from attending preceptors who unfortunately are caught up in other patient cases for billing purposes. This reduces the time necessary to continue to provide quality patient care but also impacts the value of educational pearls that can be learned from these interactions.
As a resident, I believe there should be an exception to the annual physical or wellness exams so that there can be more autonomy and efficiency in the clinic. I am in favor of not requiring precepting for these common and low risk medical visits.
As a resident physician, I fully support this resolution. This resolution enables autonomy and valuable education to best support my patients.
I support this resolution. Residency education relies on appropriate supervision though overdoing it has a direct negative effect in occupying more time of the attending to see the patient the resident has already seen and discussed the patient, leaving less time for meaningful educational time in these cases.
As a resident in family medicine, I am in support of this resolution as it will allow for more resident autonomy and leave more time to precept more complex cases. Precepting visits in a more thoughtful way is also a more efficient use of time, and ultimately makes visits more efficient for patients.
As a family medicine resident, I fully support this resolution. The current interpretation of the primary care exception far too broad. It poses a significant hindrance to my education, developing physician autonomy, and availability of my faculty to give high quality feedback during clinic hours.
I fully support this resolution. The PCE reduces my autonomy as a resident and in turn, reduces my confidence as a learner.
As a resident, I fully support this resolution. It would encourage longitudinal patient care and ultimately the trust built into the patient-resident relationship. This will set us up for the best success in future practice as attendings.
As a current resident, I believe this resolution will enhance my education and actually contribute to more appropriate and efficient supervision. If a faculty member has to take time to rush and see a routine physical exam of mine, that will take time away from seeing an acutely ill patient of one of my colleagues that actually requires their attention.
I agree with the exception proposed above. Taking time to evaluate every normal physical exam takes away from more acute cases that need precepted.
I support this resolution. Applications of PCE takes away from resident autonomy, and takes preceptors away from complex cases that will require more time and attention. PCE currently removes resident autonomy and takes away patient trust in resident’s ability to provide care. PCE provides patient’s with the perception that their PCP resident shouldn’t be fully trusted and that their work is not valid. This initiative will ultimately harm patient care by removing oversight from cases that actually need it and by eroding patient-provider trust.
I support the resolution—PCE limits access to attendings, which hurts both individualized resident education and clinical care.
As a family medicine resident, I fully support this resolution as it provides the opportunity for the following benefits: more autonomy as a resident, an increased amount of confidence in my abilities by the patient, greater efficiency by utilizing our attending physicians to staff more complex cases, and added value to our patients by decreasing the time they spend potentially waiting to be seen.
As a resident, I fully support this resolution. When the PCE is applied to wellness visits, time is taken away from sicker patients who need more time to precept. I ask that the PCE exclude wellness visits, since patients generally do not need items that would require precepts by.
As a resident physician, I fully support this resolution. PCE negatively impacts patient care delivery by restricting the amount of time we are able to spend with our patients directly for evaluation and critical medical decision making.
I fully support this resolution. As a resident, the extra strain placed on us and our preceptors leads to diminished supervision and delays patient care. For example, I have been in a situation where a preceptor has been unavailable to see a well child after a normal exam without any new concerns. Having to wait for a preceptor to see them face to face in this situation lead to the child missing another important appointment they had that day. Down the line they had to miss extra school due to rescheduling that appointment.
I fully support this resolution. These staffing requirements diminish my individualized learning, as preceptors must further divide their time, detracting from both thoughtful observation of my patient interactions and direct supervision in high-acuity situations.
As a medical educator and APD of a residency program, I am very concerned about the inappropriate interpretation and application of the PCE to all payors and all CPT codes within the framework of a residency practice. The inability to apply the PCE to well child visits and adult physicals are specifically problematic, as they have negative impacts on residents, patients, and attendings. Residents lose autonomy over patient care, may have decreased educational time, and may have decreased visits due to this misapplication as preceptors are required to see these patients for no reason outside of billing requirements. Patients may have decreased trust or confidence in their resident physician, altered continuity of care, or decreased satisfaction based on this interpretation of the PCE. Finally, attending physicians may have decreased ability to supervise and teach residents as their time is jeopardized seeing “well physicals” as opposed to more actively overseeing higher acuity cases. In summary, I fully support this OAFP resolution to reexamine the application of the PCE to additional wellness-based CPT codes.
I would like to add my support to the resolution. As a Family Medicine teacher and an Associate Program Director, I have seen first hand how the application of the Primary Care Exception to all payors has negatively impacted the educational process without any discernible improvement to patient safety or teaching. Indeed, a significant amount of my clinic precepting time is now seeing patients who are here for physicals or well child visits. It interrupts time that can be spent seeing adults and children who are ill and diminishes the amount of time I have available to view residents in their interactions with patients (and provide coaching) and assist them in practice-based learning.
As a resident, I fully support this resolution which will allow for resident autonomy. This will give preceptors time to spend with residents who are earlier in their training which will help increase resident confidence and ultimately improve patient care.