The Primary Care Exception During and After a Public Health Emergency

The Primary Care Exception (PCE) in US graduate medical education allows billing for low complexity outpatient primary care visits with indirect faculty supervision, where the faculty does not directly see the patient. The PCE historically applied only to lower complexity billing codes; but during the COVID-19 public health emergency (PHE) from March 2020 to May 2023, the PCE was expanded to include moderate and high complexity visits. Prior PCE studies have evaluated family medicine residencies before the 2021 update to the Evaluation and Management Services guidelines, which include different definitions of complexity. This is the first study to evaluate the billing impact of PCE in a primary care residency of internal medicine after the Evaluation and Management Services update.

We conducted a retrospective billing data evaluation of 99213, 99214, and 99215 billing codes from July to September 2022 (during PHE) and July to September 2023 (post-PHE) in a single institution internal medicine residency clinic. We assessed the frequencies using χ2.

A total of 11,358 patient visits met criteria. During the PHE, the majority were billed 99214 (4,602 of 5,557, or 82.8%) followed by 99213 (870 of 5,557, or 15.7%). Post-PHE, the majority were 99213 (4,000 of 5,801, or 68.3%) followed by 99214 (1,742 of 5,801, or 30.6%).

We observed an absolute 52.2% higher use of 99214 during the COVID-19 PHE expansion of the PCE. This finding has important implications for both clinic operations and education.