Family medicine resident billing and lost revenue: a regional cross-sectional study

The financial margins for primary care clinics and residencies are narrow. It is important that residents bill properly for educational and financial purposes as well as for compliance. This study compares resident and attending Evaluation and Management (E&M) coding from family medicine residency programs across a five-state region, with established billing benchmarks.

We collected established visit E&M codes for faculty and residents from a network of family medicine residencies in the Northwest United States over a 6-month period. Aggregated codes were compared to billing benchmarks from the Medical Group Management Association (MGMA) to estimate effects on revenue from these visits.

We obtained coding data for 131,788 established problem-focused visits from 353 residents and 186 faculty physicians in 16 of 18 eligible family medicine residencies. Both residents and faculty billed lower numbers of high complexity codes than MGMA benchmarks. PGY-1s coded higher numbers of high complexity codes than PGY-3s. Annual estimated revenue loss was $481,654 for the programs overall.

Residents do not bill established visits at the level of generally accepted benchmarks, which contributes to significant financial losses for programs and carries regulatory implications. The reasons for incorrect billing need to be established and interventions developed to overcome these barriers.