Study Examines Complexity of Visits With Elderly

A recent study of 392 videotaped office visits found that primary care physicians cover an average of 6.5 topics in routine encounters with elderly patients, significantly more topics than some earlier studies found. The research, which was published online Jan. 24 and which is expected to appear in the April or June issue of Health Services Research, may have implications for coding and reimbursement, say the authors and others.

"Time Allocation in Primary Care Office Visits" reports on a study led by Ming Tai-Seale, Ph.D., M.P.H., associate professor in the health policy and management department at Texas A&M Health Science Center's School of Rural Public Health, College Station. The study abstract is available free online; the full-text article costs $29.

The study was based on an examination of videotapes of physician-patient encounters recorded for a 2002 study supported by the National Institute on Aging and on surveys of patients and physicians. The 35 physicians in the videotapes, which were made between 1998 and 2000, came from a salaried group practice in an academic medical center in the Southwest, a managed care group practice in a Midwestern suburb and various fee-for-service inner-city solo practices in one Midwestern city.

For the study, the authors defined topic as "an issue that required a specific response by the physician or patient." They categorized the percentages of time spent on various types of topics per visit as follows:

"While there are typically three to four biomedical topics raised in most visits, a broader definition of topics finds more subjects of discussion," say the authors. "All compete for visit time."

The average visit time with patients 65 and older is 17.4 minutes, with the major topic taking an average of 5.3 minutes and each of the other topics taking an average of 1.1 minutes, the authors say.

Regarding current payment systems, the authors observe, "Incentives in prevailing physician payments favor procedure-based patient care over time-intensive evaluation and management care. Much of what physicians do to help their patients during an office visit would be virtually impossible to be captured in a fee schedule or a pay-for-performance system."

For example, issues such as a move to a nursing home take time to address and "tend to be under-represented in medical records," say the authors. Physicians should be given resources and incentives to build relationships with patients, the authors advise.

The authors of the current study refer to an earlier study report from the Wisconsin Research Network, or WReN, "How Many Problems Do Family Physicians Manage at Each Encounter? A WReN Study." That study, led by John Beasley, M.D., professor of family medicine at the University of Wisconsin School of Medicine and Public Health, Madison, found clinicians covered an average of 3.9 problems per visit with an elderly patient, compared with the 6.5 topics identified in the new study.

"I don't think it's surprising that, using videotapes, they (Tai-Seale and her co-authors) came up with more problems per visit," said Beasley. "The take-home is that this is really complex stuff. Almost half of the visits in our study had four or more problems. You can't even put all the problems on the Medicare form."

Indeed, the Medicare paper claim form has only four diagnosis code fields, said Cynthia Hughes, coding and compliance specialist in the AAFP Practice Support Division, in a recent interview. And although the electronic claim form is being revised to allow up to eight diagnosis codes, payer systems typically cannot consider more than four codes, she said. "However, there may be value in having the additional diagnoses as part of the record of the claim in the payer's system. Should a claim be pulled for an internal payer review, the additional diagnosis codes may help the reviewer understand the intensity of the services."

Physicians who cover multiple problems in a visit should "document everything regarding each problem -- all the management considerations and the final decisions," said Hughes. "Unfortunately, when somebody's auditing a chart, they're often not knowledgeable enough to infer that the physician considered several management options and the comorbid conditions."

The CPT manual lists "typical" face-to-face times for the 99212 to 99215 evaluation and management codes -- such as 25 minutes for a 99214 visit -- said Hughes, and if more than half the time is spent counseling or coordinating care, the service can be billed based on time.

However, the length of visit time is not necessarily proportional to the visit's complexity or to the selection of a CPT level-of-service code, explained Bruce Bagley, M.D., AAFP's medical director for quality improvement, in a recent interview. "Some physicians think you have to spend the full 25 minutes face-to-face, but in reality, you need the elements for the history, physical and complex decision-making, and those elements are often easy to achieve in less time. And sometimes you can handle three or four problems simultaneously."