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The Primary Care Exception During and After a Public Health Emergency
Stephen Fuest1, Peter J McDonnell2, Nickole Forget2
1Division of General Internal Medicine, Department of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO.
Family Medicine
|May 8, 2026
Summary
The Primary Care Exception (PCE) allowed higher complexity billing during the COVID-19 public health emergency (PHE). Post-PHE, billing shifted to lower complexity codes, impacting residency clinic operations and education.
Area of Science:
- Medical Education
- Health Services Research
- Primary Care
Background:
- The Primary Care Exception (PCE) in US graduate medical education permits billing for outpatient primary care visits with indirect faculty supervision.
- Historically, PCE applied only to lower complexity billing codes.
- The COVID-19 public health emergency (PHE) expanded PCE to include moderate and high complexity visits from March 2020 to May 2023.
Purpose of the Study:
- To evaluate the billing impact of the expanded Primary Care Exception (PCE) in an internal medicine residency clinic.
- To assess changes in billing code utilization before and after the COVID-19 PHE.
Main Methods:
- Retrospective analysis of billing data for codes 99213, 99214, and 99215.
- Data collected from July to September 2022 (during PHE) and July to September 2023 (post-PHE) at a single internal medicine residency clinic.
- Frequency analysis using chi-squared tests.
Main Results:
- A total of 11,358 patient visits were analyzed.
- During the PHE (2022), 82.8% of visits were billed as 99214 (high complexity) and 15.7% as 99213 (low complexity).
- Post-PHE (2023), billing shifted significantly, with 68.3% of visits billed as 99213 and 30.6% as 99214.
Conclusions:
- The study observed a 52.2% absolute increase in the use of 99214 billing codes during the COVID-19 PHE expansion of the PCE.
- This shift has significant implications for clinic operations and medical education within residency programs.
- The findings highlight the impact of temporary policy changes on healthcare billing and training.
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