The Intensity of Physicians’ Work in Patient Visits: Implications for the Coding of Patient Evaluation and Management Services

The authors propose a new coding evaluation for physicians that more accurately reflects the amount of work involved, is easy to record, avoids the complexities of proposed and current coding procedures, and fosters efficient practice. This article presents the results of a study conducted by the Physician Payment Commission to identify factors correlated with actual physician work performed in the course of 19,143 office and hospital visits. Three hundred ninety-nine physicians from three specialties (urology, rheumatology, and internal medicine) participated. They recorded the exact length of an average of 57 concurrent patient visits taking place in the office or hospital room. They also noted the patient’s age, whether the patient was new or returning, whether the visit was the result of a physician referral, the nature of the complaint (new or ongoing), and the presence of any cognitive or physical impairments. For office visits, the encounter time was measured from the moment the patient was escorted to the consultation room to the time the patient left. Hospital visits were measured from the first to the last contact with the patient or the patient’s chart.Evaluation and management services on the day of the visit were measured by recording stopping and starting times for reviewing records, taking the patient history and performing a physical examination, counseling the patient and family members, entering information on the chart or dictating, making contact with other providers, making clinical contact with the house staff, and scheduling tests and obtaining test results. The amount of time spent on evaluation and management services before and after the visit was estimated for each patient.A typical patient vignette (one appropriate for each specialty) was developed to provide the physician with a benchmark for estimating the amount of work required for each visit. The vignette was assigned a value of 100, and the work required for each actual visit was compared with the hypothetical one and scored as higher or lower. A study commissioned by the US Congress to provide a resource-based relative-value scale for Medicare used a similar comparison technique called magnitude estimation.Statistical analysis was based on a predicted total work value of 100 for a 30-minute patient encounter. A model was developed to predict the total amount of work involved in visits with different characteristics and to predict the total amount of work per unit of encou