Validating CPT typical times for Medicare office evaluation and management (E/M) services

Area of Science:

• Health Economics
• Medical Practice Management
• Public Health Policy

Background:

• The Medicare Fee Schedule is reviewed every five years to adjust physician work effort valuations for office visits.
• Accurate physician time data is crucial for fair Medicare reimbursement and resource allocation.

Purpose of the Study:

• To compare physician face-to-face visit times reported in the National Ambulatory Care Survey (NAMCS) with times used in Medicare billing.
• To assess potential overstatements in current Medicare reimbursement guidelines for physician office visits.

Main Methods:

• Utilized physician face-to-face time data from the National Ambulatory Care Survey (NAMCS).
• Compared NAMCS data with guideline office visit times associated with Medicare claims from 1997-1998.
• Analyzed discrepancies across different patient types and medical specialties.

Main Results:

• Medicare billed visit times were, on average, 9% longer than those reported in NAMCS.
• Visits with new patients showed a larger discrepancy, with Medicare billed times being 32% longer.
• Surgeons and dermatologists exhibited the most significant differences between Medicare and NAMCS reported times.

Conclusions:

• Current Medicare guideline times for physician office visits may be overstated.
• Overstated intraservice work effort, indicated by time correlations, suggests a need for Medicare payment reductions.
• Potential upcoding of visit content to higher CPT codes may also contribute to inflated billed times, warranting payment adjustments.