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July 2016

Time-Based Billing: What Primary Care in the United States Can Learn From Switzerland

Author Affiliations
  • 1Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland
  • 2Section of General Internal Medicine, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon
  • 3Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, Oregon
JAMA Intern Med. 2016;176(7):881-882. doi:10.1001/jamainternmed.2016.2230

I slipped into the small conference room and quickly understood the topic of the day: billing. “Now with the complexity of our patients, most of our visits should be level 4s. Level 4 visits are for established patients that require complex decision making. Remember, you will need to document either a detailed review of systems or physical exam to bill for a level 4,” the clinic director was explaining. My colleagues were mostly catching up on emails and laboratory results, only partially listening, and focused on their clinical work. I looked at my schedule; I had nearly all 15-minute visits ahead of me that day, and my first patient had already checked in late. Regardless, that afternoon in the 32nd minute of a “15 minute appointment” with an 82-year-old woman that required a cognitive assessment and comprehensive medication reconciliation, I made sure to perform the required physical examination, as the alternative, a 9-point review of systems, was not feasible. In my note, I documented my examination and a sufficient number of stable chronic illnesses to bill for a level 4 visit. It seemed normal that my scheduled visit time was inadequate and that I needed to justify billing by meeting elaborate requirements unrelated to my patient’s needs.

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