Primary Care

APPENDIX C
Survey Instruments

ASPE Physician Time Use Under the MFS---Physician Survey
06/10/2013
XXXX-NEW

Survey of Clinical Time for Selected Radiology Services
Thank you for taking the me to fill out this ques onnaire. We are interested in gathering informa on from
radiologists like yourself to be er understand the clinical me that goes into providing health care services
to your pa ents. The survey ques ons cover six different services that radiologists rou nely provide. Please
consider ALL of your pa ents in your responses, regardless of their age, health status, or type of insurance.
Filling out this survey is voluntary. Your answers to these ques ons will be kept confiden al. Results of this
survey will be reported only in the aggregate; you or your prac ce will not be iden fied in any way. If you have
any ques ons, please call the Study Manager, Lourdes Suárez, at 1-877-754-6104.

We are interested in obtaining feedback from physicians with a primary area of prac ce in

Radiology
Radiology is your primary area of prac ce  Please mark the box and conƟnue to
the next page.
Radiology is not your primary area of prac ce  Please mark the box and return this
quesƟonnaire in the enclosed envelope.
We appreciate your Ɵme.

According to the Paperwork Reduc on Act of 1995, no persons are required to respond to a collec on of informa on unless it
displays a valid OMB control number. The valid OMB control number for this informa on collec on is XXXX-NEW. The me required
to complete this informa on collec on is es mated to average 20 minutes per response, including the me to review instruc ons,
search exis ng data resources, gather the data needed, and complete and review the informa on collec on. If you have comments
concerning the accuracy of the me es mate(s) or sugges ons for improving this form, please write to: FILL IN CONTACT INFO HERE
A n: PRA Reports Clearance Officer, Mail Stop C4–26–05, Bal more, Maryland 21244–1850.

AMA-CARDIOLOGY

Page 1 of 8

Sec on A
Es mates of service me
In this sec on, we ask about the me it takes you to provide six specific services. These services are iden fied on the
following pages by the CPT code and the service descrip on from the 2013 CPT manual. For each service, please provide
your best es mate of the me you usually spend providing the service.

Please read the following informa on to guide you in es ma ng your service me:
1. Please do not include the following in your intra-service me es mate:
• Time related to any ac vi es that are billed separately, such as:
•
•
•
•

any E/M service provided in conjunc on with the main service being asked about in the survey,
post-opera ve pain management procedures,
invasive monitoring procedures,
cri cal care services.

• Visits that are typically part of a global billing period, such as a post-opera ve visit, should be included in your
post-service me es mate.
• Time spent by Residents providing a service with you or me spent by you in teaching Residents while providing a
service. Es mate your me as if Residents were not present.
• Time spent by technicians, technologists, and other clinical staff.
2. In this survey, we refer to physician assistants (PAs), nurse prac
you in providing the study services.

oners (NPs), and surgical assistants who work with

• Please do not include the me contributed by these prac oners, such as the me it takes a surgical assistant to
“open and close” a pa ent at surgery, in your own me es mates. We will be asking you to es mate the me of
these prac oners separately.
3. We are interested in understanding each component of
intra-service, and post-service:

me separately, defined below as pre-service,

• Pre-service: For nonsurgical services, such as evalua on and management (E/M) services or nonsurgical
procedures, pre-service work includes preparing to see the pa ent, reviewing records, and communica ng with
other professionals.
• Intra-service: For nonsurgical services, such as E/M services or nonsurgical procedures, the intra-service work
includes the work provided while the physician is with the pa ent and/or family, or “face-to-face” me.
• Post-service: For nonsurgical services such as E/M services or nonsurgical procedures, the post-service work
includes arranging for further services, reviewing results of studies, and communica ng further with the pa ent,
family, and other professionals, which may include wri en and telephone reports, as well as calls to the pa ent.

Page 2 of 8

70450: CT—Head or Brain
Computed tomography, head or brain; without contrast material.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (70450), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

%

74177: CT—Abdominal and Pelvis
Computed tomography, abdomen and pelvis; with contrast material(s).

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (74177), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

b. With a PA or NP
providing assistance

Pre

Intra

%

%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 3 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

G0202: Screening Mammography—Digital
Screening mammography, producing direct digital image, bilateral, all views.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (G0202), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

%

76705: Ultrasound—Abdomen
Ultrasound, abdominal, real me with image documenta on; limited (eg, single organ, quadrant, follow-up).

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (76705), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

b. With a PA or NP
providing assistance

Pre

Intra

%

%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 4 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

71020: Chest X-Ray
Radiological Examina on, Chest, 2 Views, Frontal and Lateral.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (71010), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

%

70553: MRI—Brain
Magne c resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and
further sequences.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to the next page, Section B

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (70553), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

b. With a PA or NP
providing assistance

Pre

Intra

%

%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 5 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

Sec on B
This sec on includes ques ons about your prac ce.
Please think about the office loca on where you spend the most direct pa ent care hours.
If you split your me equally, select the prac ce you have been with the longest.
B1.

Which of the following best describes the office loca on where you spend the most direct
pa ent care hours?
Solo practice  Skip to B4
Single specialty group
Multispecialty group
Medical school faculty practice
Hospital

B2.

How many full me equivalent (FTE) physicians are associated with this prac ce loca on?
Please answer thinking about the loca on where you spend the most of your direct pa ent care hours.
2 – 5 physicians
6 – 10 physicians
11 – 30 physicians
31 – 100 physicians
More than 100 physicians

B3.

How many of these FTE physicians prac ce primarily Radiology, regardless of subspecialty? Please
es mate to the best of your ability.
Physicians

B4.

How many FTE nurse prac oners, physician assistants, and assistants-at-surgery prac ce in the
same specialty or department as you, at your primary loca on? Please es mate to the best of
your ability.
Nurse prac

oners, physician assistants, and assistants-at-surgery

Page 6 of 8

B5.

Approximately how many years have you been working in this se ng?
Years

B6.

Which of the following best describes the electronic health records (EHR) adoption status at your
primary practice location?
We do not have an EHR system.
We are not ac vely using an EHR system but we have one installed.
We are ac vely using an EHR system that was installed within the past 18 months.
We are ac vely using an EHR system that was installed more than 18 months ago.

Sec on C
This sec on includes ques ons about you and your work style.
C1.

What is your age?
Less than 35 years of age
35 to 44 years of age
45 to 54 years of age
55 or older

C2.

Approximately how many years have you been prac cing in the specialty indicated on the
cover page of this ques onnaire?
Years

Page 7 of 8

C3.

During a typical week, approximately how many total hours do you spend in all
medically related ac vi es? Medically related ac vi es are defined as me spent on administra ve
tasks, professional ac vi es, and direct pa ent care but not me spent on call while not trea ng
pa ents.
Less than 20 hours
20 to 39 hours
40 to 59 hours
60 hours or more

C4.

Approximately what percentage of this me is spent on direct pa ent care? Direct pa ent
care includes ac vi es such as seeing pa ents, performing surgery or procedures, telephone and email
communica ons with pa ents and their families, and me spent on pa ent record-keeping, pa entrelated office work, interpre ng tests and imaging, and travel me associated with direct pa ent care.
% of me spent on direct pa ent care

C5.

Which of the following describes your basic compensa on?
Fixed salary
Shift, hourly, or other time-based payment
Share of practice billings or workload (e.g. fee-for-service)
Other method, please describe:

C6.

Are you eligible to earn income through any type of bonus or incen ve plan? Mark yes if you receive
periodic adjustments, bonuses, returns on withholds, or any type of supplemental payments, either
from your prac ce or from health plans.
Yes
No

Thank you for completing this questionnaire.
Please check to see that all questions are answered.
Please mail these forms to us at the address below. A postage-paid envelope is provided.
Survey of Clinical Time, c/o Lourdes Suárez, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-754-6104

Page 8 of 8

ASPE Physician Time Use Under the MFS---Physician Survey
06/10/2013
XXXX-NEW

Survey of Clinical Time for Selected Orthopedic Services
Thank you for taking the me to fill out this ques onnaire. We are interested in gathering informa on from
orthopedists like yourself to be er understand the clinical me that goes into providing health care services
to your pa ents. The survey ques ons cover six different services that orthopedists rou nely provide. Please
consider ALL of your pa ents in your responses, regardless of their age, health status, or type of insurance.
Filling out this survey is voluntary. Your answers to these ques ons will be kept confiden al. Results of this
survey will be reported only in the aggregate; you or your prac ce will not be iden fied in any way. If you have
any ques ons, please call the Study Manager, Lourdes Suárez, at 1-877-754-6104.

We are interested in obtaining feedback from physicians with a primary area of prac ce in

Orthopedics
Orthopedics is your primary area of prac ce  Please mark the box and conƟnue to
the next page.
Orthopedics is not your primary area of prac ce  Please mark the box and return this
quesƟonnaire in the enclosed envelope.
We appreciate your Ɵme.

According to the Paperwork Reduc on Act of 1995, no persons are required to respond to a collec on of informa on unless it
displays a valid OMB control number. The valid OMB control number for this informa on collec on is XXXX-NEW. The me required
to complete this informa on collec on is es mated to average 20 minutes per response, including the me to review instruc ons,
search exis ng data resources, gather the data needed, and complete and review the informa on collec on. If you have comments
concerning the accuracy of the me es mate(s) or sugges ons for improving this form, please write to: FILL IN CONTACT INFO HERE
A n: PRA Reports Clearance Officer, Mail Stop C4–26–05, Bal more, Maryland 21244–1850.

AMA-CARDIOLOGY

Page 1 of 8

Sec on A
Es mates of service me
In this sec on, we ask about the me it takes you to provide six specific services. These services are iden fied on the
following pages by the CPT code and the service descrip on from the 2013 CPT manual. For each service, please provide
your best es mate of the me you usually spend providing the service.

Please read the following informa on to guide you in es ma ng your service me:
1. Please do not include the following in your intra-service me es mate:
• Time related to any ac vi es that are billed separately, such as:
•
•
•
•

any E/M service provided in conjunc on with the main service being asked about in the survey,
post-opera ve pain management procedures,
invasive monitoring procedures,
cri cal care services.

• Visits that are typically part of a global billing period, such as a post-opera ve visit, should be included in your
post-service me es mate.
• Time spent by Residents providing a service with you or me spent by you in teaching Residents while providing a
service. Es mate your me as if Residents were not present.
• Time spent by technicians, technologists, and other clinical staff.
2. In this survey, we refer to physician assistants (PAs), nurse prac
you in providing the study services.

oners (NPs), and surgical assistants who work with

• Please do not include the me contributed by these prac oners, such as the me it takes a surgical assistant to
“open and close” a pa ent at surgery, in your own me es mates. We will be asking you to es mate the me of
these prac oners separately.
3. We are interested in understanding each component of
intra-service, and post-service:

me separately, defined below as pre-service,

• Pre-service: For surgical services, the pre-service period includes all usual physician services provided from
the day before surgery un l the opera ve procedure begins. For nonsurgical services, such as evalua on and
management (E/M) services or nonsurgical procedures, pre-service work includes preparing to see the pa ent,
reviewing records, and communica ng with other professionals.
• Intra-service: For surgical services, the intra-service or intraopera ve period includes all “skin-to-skin”
(start of the skin incision un l the incision is closed) physician work that is a necessary part of the procedure. For
nonsurgical services, such as E/M services or nonsurgical procedures, the intra-service work includes the work
provided while the physician is with the pa ent and/or family, or “face-to-face” me.
• Post-service: For surgical services with a global period of zero days, the post-service period includes all postopera ve care following skin closure, on the day of surgery. For surgical services with global periods of 10 or 90
days, the post-service work includes the same work as a surgical service with a global period of zero days, and, in
addi on, includes post-opera ve hospital and office visits within the assigned global period of 10 or 90 days. For
nonsurgical services such as E/M services or nonsurgical procedures, the post-service work includes arranging
for further services, reviewing results of studies, and communica ng further with the pa ent, family, and other
professionals, which may include wri en and telephone reports, as well as calls to the pa ent.

Page 2 of 8

29881: Surgical Arthroscopy—Knee
Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of
ar cular car lage (chondroplasty), same or separate compartment(s), when performed.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate the me you spend providing the service and the me spent by the combina on of Assistants-at-Surgery, PAs, and NPs working
with you. If you do not work with an assistant, mark the box for "No Assistant" in ques on 3.

2.

3.

Your me (in minutes per service)
Pre

4.

Intra

Assistant’s at Surgery, PAs, and NPs me (in minutes per service)
Post

Pre

Intra

Post

No Assistant

Please indicate the number of visits you usually provide for pa ents requiring this service within the 90-day global billing period,
in addi on to the main service.
Hospital-based:

Office or Outpa ent:

20610: Arthrocentesis—Major Joint or Bursa
Arthrocentesis, aspira on and/or injec on; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa).

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate the me you spend providing the service and the me spent by the combina on of Assistants-at-Surgery, PAs, and NPs working
with you. If you do not work with an assistant, mark the box for "No Assistant" in ques on 3.

2.

3.

Your me (in minutes per service)
Pre

Intra

Assistant’s at Surgery, PAs, and NPs me (in minutes per service)
Post

Pre

Page 3 of 8

Intra

Post

No Assistant

27130: Arthroplasty—Hip
Arthroplasty, acetabular and proximal femoral prosthe c replacement (total hip arthroplasty), with or without autogra or allogra .

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate the me you spend providing the service and the me spent by the combina on of Assistants-at-Surgery, PAs, and NPs working
with you. If you do not work with an assistant, mark the box for "No Assistant" in ques on 3.

2.

3.

Your me (in minutes per service)
Pre

4.

Intra

Assistant’s at Surgery, PAs, and NPs me (in minutes per service)
Post

Pre

Intra

Post

No Assistant

Please indicate the number of visits you usually provide for pa ents requiring this service within the 90-day global billing period,
in addi on to the main service.
Hospital-based:

Office or Outpa ent:

27447: Arthroplasty—Knee
Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty).

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate the me you spend providing the service and the me spent by the combina on of Assistants-at-Surgery, PAs, and NPs working
with you. If you do not work with an assistant, mark the box for "No Assistant" in ques on 3.

2.

3.

Your me (in minutes per service)
Pre

4.

Intra

Assistant’s at Surgery, PAs, and NPs me (in minutes per service)
Post

Pre

Intra

Post

No Assistant

Please indicate the number of visits you usually provide for pa ents requiring this service within the 90-day global billing period,
in addi on to the main service.
Hospital-based:

Office or Outpa ent:

Page 4 of 8

27245: Treatment Femoral Fracture—Intertrochanteric
Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without
interlocking screws and/or cerclage.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate the me you spend providing the service and the me spent by the combina on of Assistants-at-Surgery, PAs, and NPs working
with you. If you do not work with an assistant, mark the box for "No Assistant" in ques on 3.

2.

3.

Your me (in minutes per service)
Pre

4.

Intra

Assistant’s at Surgery, PAs, and NPs me (in minutes per service)
Post

Pre

Intra

Post

No Assistant

Please indicate the number of visits you usually provide for pa ents requiring this service within the 90-day global billing period,
in addi on to the main service.
Hospital-based:

Office or Outpa ent:

99214: Office Visit—Established Pa ent, Level 4
Office or other outpa ent visit for the evalua on and management of an established pa ent, which requires at least 2 of these 3 key
components: A detailed history; A detailed examina on; Medical decision making of moderate complexity. Counseling and/or coordina on
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the
problem(s) and the pa ent’s and/or family’s needs. Usually, the presen ng problem(s) are of moderate to high severity.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to the next page, Section B

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (99214), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

b. With a PA or NP
providing assistance

Pre

Intra

%

%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 5 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

Sec on B
This sec on includes ques ons about your prac ce.
Please think about the office loca on where you spend the most direct pa ent care hours.
If you split your me equally, select the prac ce you have been with the longest.
B1.

Which of the following best describes the office loca on where you spend the most direct
pa ent care hours?
Solo practice  Skip to B4
Single specialty group
Multispecialty group
Medical school faculty practice
Hospital

B2.

How many full me equivalent (FTE) physicians are associated with this prac ce loca on?
Please answer thinking about the loca on where you spend the most of your direct pa ent care hours.
2 – 5 physicians
6 – 10 physicians
11 – 30 physicians
31 – 100 physicians
More than 100 physicians

B3.

How many of these FTE physicians prac ce primarily Orthopedics, regardless of subspecialty? Please
es mate to the best of your ability.
Physicians

B4.

How many FTE nurse prac oners, physician assistants, and assistants-at-surgery prac ce in the
same specialty or department as you, at your primary loca on? Please es mate to the best of
your ability.
Nurse prac

oners, physician assistants, and assistants-at-surgery

Page 6 of 8

B5.

Approximately how many years have you been working in this se ng?
Years

B6.

Which of the following best describes the electronic health records (EHR) adoption status at your
primary practice location?
We do not have an EHR system.
We are not ac vely using an EHR system but we have one installed.
We are ac vely using an EHR system that was installed within the past 18 months.
We are ac vely using an EHR system that was installed more than 18 months ago.

B7.

What percent of the prac ce’s pa ents rely on the following sources for payment for the services
they receive? Please es mate to the best of your ability.
% Medicare (including Medicare Advantage health plans)
% Medicaid and other public sources

Sec on C
This sec on includes ques ons about you and your work style.
C1.

What is your age?
Less than 35 years of age
35 to 44 years of age
45 to 54 years of age
55 or older

C2.

Approximately how many years have you been prac cing Orthopedics?
Years

Page 7 of 8

C3.

During a typical week, approximately how many total hours do you spend in all
medically related ac vi es? Medically related ac vi es are defined as me spent on administra ve
tasks, professional ac vi es, and direct pa ent care but not me spent on call while not trea ng
pa ents.
Less than 20 hours
20 to 39 hours
40 to 59 hours
60 hours or more

C4.

Approximately what percentage of this me is spent on direct pa ent care? Direct pa ent
care includes ac vi es such as seeing pa ents, performing surgery or procedures, telephone and email
communica ons with pa ents and their families, and me spent on pa ent record-keeping, pa entrelated office work, interpre ng tests and imaging, and travel me associated with direct pa ent care.
% of me spent on direct pa ent care

C5.

Which of the following describes your basic compensa on?
Fixed salary
Shift, hourly, or other time-based payment
Share of practice billings or workload (e.g. fee-for-service)
Other method, please describe:

C6.

Are you eligible to earn income through any type of bonus or incen ve plan? Mark yes if you receive
periodic adjustments, bonuses, returns on withholds, or any type of supplemental payments, either
from your prac ce or from health plans.
Yes
No

Thank you for completing this questionnaire.
Please check to see that all questions are answered.
Please mail these forms to us at the address below. A postage-paid envelope is provided.
Survey of Clinical Time, c/o Lourdes Suárez, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-754-6104

Page 8 of 8

ASPE Physician Time Use Under the MFS---Physician Survey
06/10/2013
XXXX-NEW

Survey of Clinical Time for Selected Ophthalmology Services
Thank you for taking the me to fill out this ques onnaire. We are interested in gathering informa on from
ophthalmologists like yourself to be er understand the clinical me that goes into providing health care services
to your pa ents. The survey ques ons cover six different services that ophthalmologists rou nely provide. Please
consider ALL of your pa ents in your responses, regardless of their age, health status, or type of insurance.
Filling out this survey is voluntary. Your answers to these ques ons will be kept confiden al. Results of this
survey will be reported only in the aggregate; you or your prac ce will not be iden fied in any way. If you have
any ques ons, please call the Study Manager, Lourdes Suárez, at 1-877-754-6104.

We are interested in obtaining feedback from physicians with a primary area of prac ce in

Ophthalmology
Ophthalmology is your primary area of prac ce  Please mark the box and conƟnue to
the next page.
Ophthalmology is not your primary area of prac ce  Please mark the box and return this
quesƟonnaire in the enclosed envelope.
We appreciate your Ɵme.

According to the Paperwork Reduc on Act of 1995, no persons are required to respond to a collec on of informa on unless it
displays a valid OMB control number. The valid OMB control number for this informa on collec on is XXXX-NEW. The me required
to complete this informa on collec on is es mated to average 20 minutes per response, including the me to review instruc ons,
search exis ng data resources, gather the data needed, and complete and review the informa on collec on. If you have comments
concerning the accuracy of the me es mate(s) or sugges ons for improving this form, please write to: FILL IN CONTACT INFO HERE
A n: PRA Reports Clearance Officer, Mail Stop C4–26–05, Bal more, Maryland 21244–1850.

AMA-CARDIOLOGY

Page 1 of 8

Sec on A
Es mates of service me
In this sec on, we ask about the me it takes you to provide six specific services. These services are iden fied on the
following pages by the CPT code and the service descrip on from the 2013 CPT manual. For each service, please provide
your best es mate of the me you usually spend providing the service.

Please read the following informa on to guide you in es ma ng your service me:
1. Please do not include the following in your intra-service me es mate:
• Time related to any ac vi es that are billed separately, such as:
•
•
•
•

any E/M service provided in conjunc on with the main service being asked about in the survey,
post-opera ve pain management procedures,
invasive monitoring procedures,
cri cal care services.

• Visits that are typically part of a global billing period, such as a post-opera ve visit, should be included in your
post-service me es mate.
• Time spent by Residents providing a service with you or me spent by you in teaching Residents while providing a
service. Es mate your me as if Residents were not present.
• Time spent by technicians, technologists, and other clinical staff.
2. In this survey, we refer to physician assistants (PAs), nurse prac
you in providing the study services.

oners (NPs), and surgical assistants who work with

• Please do not include the me contributed by these prac oners, such as the me it takes a surgical assistant to
“open and close” a pa ent at surgery, in your own me es mates. We will be asking you to es mate the me of
these prac oners separately.
3. We are interested in understanding each component of
intra-service, and post-service:

me separately, defined below as pre-service,

• Pre-service: For surgical services, the pre-service period includes all usual physician services provided from
the day before surgery un l the opera ve procedure begins. For nonsurgical services, such as evalua on and
management (E/M) services or nonsurgical procedures, pre-service work includes preparing to see the pa ent,
reviewing records, and communica ng with other professionals.
• Intra-service: For surgical services, the intra-service or intraopera ve period includes all physician work that is a
necessary part of the procedure, from the start of the incision un l the incision is closed. For nonsurgical services,
such as E/M services or nonsurgical procedures, the intra-service work includes the work provided while the
physician is with the pa ent and/or family, or “face-to-face” me.
• Post-service: For surgical services with a global period of zero days, the post-service period includes all postopera ve care following closure of the incision, on the day of surgery. For surgical services with global periods
of 10 or 90 days, the post-service work includes the same work as a surgical service with a global period of zero
days, and, in addi on, includes post-opera ve hospital and office visits within the assigned global period of 10 or
90 days. For nonsurgical services such as E/M services or nonsurgical procedures, the post-service work includes
arranging for further services, reviewing results of studies, and communica ng further with the pa ent, family,
and other professionals, which may include wri en and telephone reports, as well as calls to the pa ent.

Page 2 of 8

67228: Photocoagula on of Re na
Treatment of extensive or progressive re nopathy, 1 or more sessions; (eg, diabe c re nopathy), photocoagula on.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below; the me you, PAs, and NPs spend providing the service;
and the me spent by a PA or NP working with you for each of the ways you provide.

2.
Thinking about all of the mes you provide this
service (17000), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

5.

%

Please indicate the number of visits you usually provide for pa ents requiring this service within the 90-day global billing period,
in addi on to the main service.
Hospital-based:

Office or Outpa ent:

92014: Eye Exam and Treatment
Ophthalmological services: comprehensive medical examina on and evalua on, with ini a on or con nua on of diagnos c and treatment
program; comprehensive, established pa ent, 1 or more visits.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (92014), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

b. With a PA or NP
providing assistance

Pre

Intra

%

%

c. Supervising a PA or NP
who provides substan al
independent care

%
Page 3 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

92134: Re nal Scan
Scanning computerized ophthalmic diagnos c imaging, posterior segment, with interpreta on and report, unilateral or bilateral; re na.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (92134), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP

%

who provides substan al
independent care

66821: Discission of Cataract
Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser)
(1 or more stages).

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate the me you spend providing the service and the me spent by the combina on of Assistants-at-Surgery, PAs, and NPs working
with you. If you do not work with an assistant, mark the box for "No Assistant" in ques on 3.

2.

3.

Your me (in minutes per service)
Pre

4.

Intra

Assistant’s at Surgery, PAs, and NPs me (in minutes per service)
Post

Pre

Intra

Post

No Assistant

Please indicate the number of visits you usually provide for pa ents requiring this service within the 90-day global billing period,
in addi on to the main service.
Hospital-based:

Office or Outpa ent:

Page 4 of 8

66984: Cataract Surgery
Extracapsular cataract removal with inser on of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg,
irriga on and aspira on or phacoemulsifica on).

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate the me you spend providing the service and the me spent by the combina on of Assistants-at-Surgery, PAs, and NPs working
with you. If you do not work with an assistant, mark the box for "No Assistant" in ques on 3.

2.

3.

Your me (in minutes per service)
Pre

4.

Intra

Assistant’s at Surgery, PAs, and NPs me (in minutes per service)
Post

Pre

Intra

Post

No Assistant

Please indicate the number of visits you usually provide for pa ents requiring this service within the 90-day global billing period,
in addi on to the main service.
Hospital-based:

Office or Outpa ent:

92083: Visual Field Exam
Visual field examina on, unilateral or bilateral, with interpreta on and report; extended examina on (eg, Goldmann visual fields with at
least 3 isopters plo ed and sta c determina on within the central 30°, or quan ta ve, automated threshold perimetry, Octopus program
G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to the next page, Section B

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (92083), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

b. With a PA or NP
providing assistance

Pre

Intra

%

%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 5 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

Sec on B
This sec on includes ques ons about your prac ce.
Please think about the office loca on where you spend the most direct pa ent care hours.
If you split your me equally, select the prac ce you have been with the longest.
B1.

Which of the following best describes the office loca on where you spend the most direct
pa ent care hours?
Solo practice  Skip to B4
Single specialty group
Multispecialty group
Medical school faculty practice
Hospital

B2.

How many full me equivalent (FTE) physicians are associated with this prac ce loca on?
Please answer thinking about the loca on where you spend the most of your direct pa ent care hours.
2 – 5 physicians
6 – 10 physicians
11 – 30 physicians
31 – 100 physicians
More than 100 physicians

B3.

How many of these FTE physicians prac ce primarily Ophthalmology, regardless of subspecialty?
Please es mate to the best of your ability.
Physicians

B4.

How many FTE nurse prac oners, physician assistants, and assistants-at-surgery prac ce in the
same specialty or department as you, at your primary loca on? Please es mate to the best of
your ability.
Nurse prac

oners, physician assistants, and assistants-at-surgery

Page 6 of 8

B5.

Approximately how many years have you been working in this se ng?
Years

B6.

Which of the following best describes the electronic health records (EHR) adoption status at your
primary practice location?
We do not have an EHR system.
We are not ac vely using an EHR system but we have one installed.
We are ac vely using an EHR system that was installed within the past 18 months.
We are ac vely using an EHR system that was installed more than 18 months ago.

B7.

What percent of the prac ce’s pa ents rely on the following sources for payment for the services
they receive? Please es mate to the best of your ability.
% Medicare (including Medicare Advantage health plans)
% Medicaid and other public sources

Sec on C
This sec on includes ques ons about you and your work style.
C1.

What is your age?
Less than 35 years of age
35 to 44 years of age
45 to 54 years of age
55 or older

C2.

Approximately how many years have you been prac cing Ophthalmology?
Years

Page 7 of 8

C3.

During a typical week, approximately how many total hours do you spend in all
medically related ac vi es? Medically related ac vi es are defined as me spent on administra ve
tasks, professional ac vi es, and direct pa ent care but not me spent on call while not trea ng
pa ents.
Less than 20 hours
20 to 39 hours
40 to 59 hours
60 hours or more

C4.

Approximately what percentage of this me is spent on direct pa ent care? Direct pa ent
care includes ac vi es such as seeing pa ents, performing surgery or procedures, telephone and email
communica ons with pa ents and their families, and me spent on pa ent record-keeping, pa entrelated office work, interpre ng tests and imaging, and travel me associated with direct pa ent care.
% of me spent on direct pa ent care

C5.

Which of the following describes your basic compensa on?
Fixed salary
Shift, hourly, or other time-based payment
Share of practice billings or workload (e.g. fee-for-service)
Other method, please describe:

C6.

Are you eligible to earn income through any type of bonus or incen ve plan? Mark yes if you receive
periodic adjustments, bonuses, returns on withholds, or any type of supplemental payments, either
from your prac ce or from health plans.
Yes
No

Thank you for completing this questionnaire.
Please check to see that all questions are answered.
Please mail these forms to us at the address below. A postage-paid envelope is provided.
Survey of Clinical Time, c/o Lourdes Suárez, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-754-6104

Page 8 of 8

ASPE Physician Time Use Under the MFS---Physician Survey
06/10/2013
XXXX-NEW

Survey of Clinical Time for Selected Family Medicine Services
Thank you for taking the me to fill out this ques onnaire. We are interested in gathering informa on from
family physicians like yourself to be er understand the clinical me that goes into providing health care services
to your pa ents. The survey ques ons cover six different services that family physicians rou nely provide. Please
consider ALL of your pa ents in your responses, regardless of their age, health status, or type of insurance.
Filling out this survey is voluntary. Your answers to these ques ons will be kept confiden al. Results of this
survey will be reported only in the aggregate; you or your prac ce will not be iden fied in any way. If you have
any ques ons, please call the Study Manager, Lourdes Suárez, at 1-877-754-6104.

We are interested in obtaining feedback from physicians with a primary area of prac ce in

Family Medicine
Family Medicine is your primary area of prac ce  Please mark the box and conƟnue to
the next page.
Family Medicine is not your primary area of prac ce  Please mark the box and return this
quesƟonnaire in the enclosed envelope.
We appreciate your Ɵme.

According to the Paperwork Reduc on Act of 1995, no persons are required to respond to a collec on of informa on unless it
displays a valid OMB control number. The valid OMB control number for this informa on collec on is XXXX-NEW. The me required
to complete this informa on collec on is es mated to average 20 minutes per response, including the me to review instruc ons,
search exis ng data resources, gather the data needed, and complete and review the informa on collec on. If you have comments
concerning the accuracy of the me es mate(s) or sugges ons for improving this form, please write to: FILL IN CONTACT INFO HERE
A n: PRA Reports Clearance Officer, Mail Stop C4–26–05, Bal more, Maryland 21244–1850.

AMA-CARDIOLOGY

Page 1 of 8

Sec on A
Es mates of service me
In this sec on, we ask about the me it takes you to provide six specific services. These services are iden fied on the
following pages by the CPT code and the service descrip on from the 2013 CPT manual. For each service, please provide
your best es mate of the me you usually spend providing the service.

Please read the following informa on to guide you in es ma ng your service me:
1. Please do not include the following in your intra-service me es mate:
• Time related to any ac vi es that are billed separately, such as:
•
•
•
•

any E/M service provided in conjunc on with the main service being asked about in the survey,
post-opera ve pain management procedures,
invasive monitoring procedures,
cri cal care services.

• Visits that are typically part of a global billing period, such as a post-opera ve visit, should be included in your
post-service me es mate.
• Time spent by Residents providing a service with you or me spent by you in teaching Residents while providing a
service. Es mate your me as if Residents were not present.
• Time spent by technicians, technologists, and other clinical staff.
2. In this survey, we refer to physician assistants (PAs), nurse prac
you in providing the study services.

oners (NPs), and surgical assistants who work with

• Please do not include the me contributed by these prac oners, such as the me it takes a surgical assistant to
“open and close” a pa ent at surgery, in your own me es mates. We will be asking you to es mate the me of
these prac oners separately.
3. We are interested in understanding each component of
intra-service, and post-service:

me separately, defined below as pre-service,

• Pre-service: For surgical services, the pre-service period includes all usual physician services provided from
the day before surgery un l the opera ve procedure begins. For nonsurgical services, such as evalua on and
management (E/M) services or nonsurgical procedures, pre-service work includes preparing to see the pa ent,
reviewing records, and communica ng with other professionals.
• Intra-service: For surgical services, the intra-service or intraopera ve period includes all “skin-to-skin”
(start of the skin incision un l the incision is closed) physician work that is a necessary part of the procedure. For
nonsurgical services, such as E/M services or nonsurgical procedures, the intra-service work includes the work
provided while the physician is with the pa ent and/or family, or “face-to-face” me.
• Post-service: For surgical services with a global period of zero days, the post-service period includes all postopera ve care following skin closure, on the day of surgery. For surgical services with global periods of 10 or 90
days, the post-service work includes the same work as a surgical service with a global period of zero days, and, in
addi on, includes post-opera ve hospital and office visits within the assigned global period of 10 or 90 days. For
nonsurgical services such as E/M services or nonsurgical procedures, the post-service work includes arranging
for further services, reviewing results of studies, and communica ng further with the pa ent, family, and other
professionals, which may include wri en and telephone reports, as well as calls to the pa ent.

Page 2 of 8

99214: Office Visit— Established Pa ent, Level 4
Office or other outpa ent visit for the evalua on and management of an established pa ent, which requires at least 2 of these 3 key
components: A detailed history; A detailed examina on; Medical decision making of moderate complexity. Counseling and/or coordina on
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the
problem(s) and the pa ent’s and/or family’s needs. Usually, the presen ng problem(s) are of moderate to high severity.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (99214), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

%

17000: Destruc on of Premalignant Lesion
Destruc on (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical cure ement), premalignant lesions
(eg, ac nic keratoses); first lesion.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (17000), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP
b. With a PA or NP
providing assistance

Pre

Intra

%

Post

Pre

Intra

Post

N/A

N/A

N/A

%

c. Supervising a PA or NP
who provides substan al
independent care

5.

%

Please indicate the number of visits you usually provide for pa ents requiring this service within the 10-day global billing period,
in addi on to the main service.
Hospital-based:

Office or Outpa ent:
Page 3 of 8

20610: Arthrocentesis—Major Joint or Bursa
Arthrocentesis, aspira on and/or injec on; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa).

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate the me you spend providing the service and the me spent by the combina on of Assistants-at-Surgery, PAs, and NPs working
with you. If you do not work with an assistant, mark the box for "No Assistant" in ques on 3.

2.

3.

Your me (in minutes per service)
Pre

Intra

Assistant’s at Surgery, PAs, and NPs me (in minutes per service)
Post

Pre

Intra

Post

No Assistant

99204: Office Visit—New Pa ent, Level 4
Office or other outpa ent visit for the evalua on and management of a new pa ent, which requires these 3 key components: A
comprehensive history; A comprehensive examina on; Medical decision making of moderate complexity. Counseling and/or coordina on of
care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s)
and the pa ent’s and/or family’s needs. Usually, the presen ng problem(s) are of moderate to high severity.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (99204), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

b. With a PA or NP
providing assistance

Pre

Intra

%

%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 4 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

93010: Electrocardiogram Interpreta on
Electrocardiogram, rou ne ECG with at least 12 leads; interpreta on and report only.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (93010), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

%

99213: Office Visit— Established Pa ent, Level 3
Office or other outpa ent visit for the evalua on and management of an established pa ent, which requires at least 2 of these 3 key
components: An expanded problem focused history; An expanded problem focused examina on; Medical decision making of low
complexity. Counseling and coordina on of care with other physicians, other qualified health care professionals, or agencies are provided
consistent with the nature of the problem(s) and the pa ent’s and/or family’s needs. Usually, the presen ng problem(s) are of low to
moderate severity.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to the next page, Section B

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (99213), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP
b. With a PA or NP
providing assistance

Pre

Intra

%
%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 5 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

Sec on B
This sec on includes ques ons about your prac ce.
Please think about the office loca on where you spend the most direct pa ent care hours.
If you split your me equally, select the prac ce you have been with the longest.
B1.

Which of the following best describes the office loca on where you spend the most direct
pa ent care hours?
Solo practice  Skip to B4
Single specialty group
Multispecialty group
Medical school faculty practice
Hospital

B2.

How many full me equivalent (FTE) physicians are associated with this prac ce loca on?
Please answer thinking about the loca on where you spend the most of your direct pa ent care hours.
2 – 5 physicians
6 – 10 physicians
11 – 30 physicians
31 – 100 physicians
More than 100 physicians

B3.

How many of these FTE physicians prac ce Family Medicine, regardless of subspecialty? Please
es mate to the best of your ability.
Physicians

B4.

How many FTE nurse prac oners, physician assistants, and assistants-at-surgery prac ce in the
same specialty or department as you, at your primary loca on? Please es mate to the best of
your ability.
Nurse prac

oners, physician assistants, and assistants-at-surgery

Page 6 of 8

B5.

Approximately how many years have you been working in this se ng?
Years

B6.

Which of the following best describes the electronic health records (EHR) adoption status at your
primary practice location?
We do not have an EHR system.
We are not ac vely using an EHR system but we have one installed.
We are ac vely using an EHR system that was installed within the past 18 months.
We are ac vely using an EHR system that was installed more than 18 months ago.

B7.

What percent of the prac ce’s pa ents rely on the following sources for payment for the services
they receive? Please es mate to the best of your ability.
% Medicare (including Medicare Advantage health plans)
% Medicaid and other public sources

Sec on C
This sec on includes ques ons about you and your work style.
C1.

What is your age?
Less than 35 years of age
35 to 44 years of age
45 to 54 years of age
55 or older

C2.

Approximately how many years have you been prac cing Family Medicine?
Years

Page 7 of 8

C3.

During a typical week, approximately how many total hours do you spend in all
medically related ac vi es? Medically related ac vi es are defined as me spent on administra ve
tasks, professional ac vi es, and direct pa ent care but not me spent on call while not trea ng
pa ents.
Less than 20 hours
20 to 39 hours
40 to 59 hours
60 hours or more

C4.

Approximately what percentage of this me is spent on direct pa ent care? Direct pa ent
care includes ac vi es such as seeing pa ents, performing surgery or procedures, telephone and email
communica ons with pa ents and their families, and me spent on pa ent record-keeping, pa entrelated office work, interpre ng tests and imaging, and travel me associated with direct pa ent care.
% of me spent on direct pa ent care

C5.

Which of the following describes your basic compensa on?
Fixed salary
Shift, hourly, or other time-based payment
Share of practice billings or workload (e.g. fee-for-service)
Other method, please describe:

C6.

Are you eligible to earn income through any type of bonus or incen ve plan? Mark yes if you receive
periodic adjustments, bonuses, returns on withholds, or any type of supplemental payments, either
from your prac ce or from health plans.
Yes
No

Thank you for completing this questionnaire.
Please check to see that all questions are answered.
Please mail these forms to us at the address below. A postage-paid envelope is provided.
Survey of Clinical Time, c/o Lourdes Suárez, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-754-6104

Page 8 of 8

ASPE Physician Time Use Under the MFS---Physician Survey
06/10/2013
XXXX-NEW

Survey of Clinical Time for Selected Cardiology Services
Thank you for taking the me to fill out this ques onnaire. We are interested in gathering informa on from
cardiologists like yourself to be er understand the clinical me that goes into providing health care services
to your pa ents. The survey ques ons cover six different services that cardiologists rou nely provide. Please
consider ALL of your pa ents in your responses, regardless of their age, health status, or type of insurance.
Filling out this survey is voluntary. Your answers to these ques ons will be kept confiden al. Results of this
survey will be reported only in the aggregate; you or your prac ce will not be iden fied in any way. If you have
any ques ons, please call the Study Manager, Lourdes Suárez, at 1-877-754-6104.

We are interested in obtaining feedback from physicians with a primary area of prac ce in

Cardiology
Cardiology is your primary area of prac ce  Please mark the box and conƟnue to
the next page.
Cardiology is not your primary area of prac ce  Please mark the box and return this
quesƟonnaire in the enclosed envelope.
We appreciate your Ɵme.

According to the Paperwork Reduc on Act of 1995, no persons are required to respond to a collec on of informa on unless it
displays a valid OMB control number. The valid OMB control number for this informa on collec on is XXXX-NEW. The me required
to complete this informa on collec on is es mated to average 20 minutes per response, including the me to review instruc ons,
search exis ng data resources, gather the data needed, and complete and review the informa on collec on. If you have comments
concerning the accuracy of the me es mate(s) or sugges ons for improving this form, please write to: FILL IN CONTACT INFO HERE
A n: PRA Reports Clearance Officer, Mail Stop C4–26–05, Bal more, Maryland 21244–1850.

AMA-CARDIOLOGY

Page 1 of 8

Sec on A
Es mates of service me
In this sec on, we ask about the me it takes you to provide six specific services. These services are iden fied on the
following pages by the CPT code and the service descrip on from the 2013 CPT manual. For each service, please provide
your best es mate of the me you usually spend providing the service.

Please read the following informa on to guide you in es ma ng your service me:
1. Please do not include the following in your intra-service me es mate:
• Time related to any ac vi es that are billed separately, such as:
•
•
•
•

any E/M service provided in conjunc on with the main service being asked about in the survey,
post-opera ve pain management procedures,
invasive monitoring procedures,
cri cal care services.

• Visits that are typically part of a global billing period, such as a post-opera ve visit, should be included in your
post-service me es mate.
• Time spent by Residents providing a service with you or me spent by you in teaching Residents while providing a
service. Es mate your me as if Residents were not present.
• Time spent by technicians, technologists, and other clinical staff.
2. In this survey, we refer to physician assistants (PAs), nurse prac
you in providing the study services.

oners (NPs), and surgical assistants who work with

• Please do not include the me contributed by these prac oners, such as the me it takes a surgical assistant to
“open and close” a pa ent at surgery, in your own me es mates. We will be asking you to es mate the me of
these prac oners separately.
3. We are interested in understanding each component of
intra-service, and post-service:

me separately, defined below as pre-service,

• Pre-service: For surgical services, the pre-service period includes all usual physician services provided from
the day before surgery un l the opera ve procedure begins. For nonsurgical services, such as evalua on and
management (E/M) services or nonsurgical procedures, pre-service work includes preparing to see the pa ent,
reviewing records, and communica ng with other professionals.
• Intra-service: For surgical services, the intra-service or intraopera ve period includes all “skin-to-skin”
(start of the skin incision un l the incision is closed) physician work that is a necessary part of the procedure. For
nonsurgical services, such as E/M services or nonsurgical procedures, the intra-service work includes the work
provided while the physician is with the pa ent and/or family, or “face-to-face” me.
• Post-service: For surgical services with a global period of zero days, the post-service period includes all postopera ve care following skin closure, on the day of surgery. For surgical services with global periods of 10 or 90
days, the post-service work includes the same work as a surgical service with a global period of zero days, and, in
addi on, includes post-opera ve hospital and office visits within the assigned global period of 10 or 90 days. For
nonsurgical services such as E/M services or nonsurgical procedures, the post-service work includes arranging
for further services, reviewing results of studies, and communica ng further with the pa ent, family, and other
professionals, which may include wri en and telephone reports, as well as calls to the pa ent.

Page 2 of 8

93458: Cardiac Catheteriza on
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injec on(s) for coronary angiography,
imaging supervision and interpreta on; with le heart catheteriza on including intraprocedural injec on(s) for le ventriculography, when
performed.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (93458), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

%

92928: Angioplasty
Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery
or branch.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (92928), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP
b. With a PA or NP
providing assistance

Pre

Intra

%
%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 3 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

93306: Echocardiogram
Echocardiography, transthoracic, real- me with image documenta on (2D), includes M-mode recording, when performed, complete, with
spectral Doppler echocardiography, and with color flow Doppler echocardiography.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (93306), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

%

93010: Electrocardiogram Interpreta on
Electrocardiogram, rou ne ECG with at least 12 leads; interpreta on and report only.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (93010), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP
b. With a PA or NP
providing assistance

Pre

Intra

%
%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 4 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

78452: Nuclear Stress Test
Myocardial perfusion imaging, tomographic (SPECT) (including a enua on correc on, qualita ve or quan ta ve wall mo on, ejec on
frac on by first pass or gated technique, addi onal quan fica on, when performed); mul ple studies, at rest and/or stress (exercise or
pharmacologic) and/or redistribu on and/or rest reinjec on.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to next service

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (78452), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP

Pre

Intra

Post

%

b. With a PA or NP

Pre

Intra

Post

N/A

N/A

N/A

%

providing assistance

c. Supervising a PA or NP
who provides substan al
independent care

%

99214: Office Visit—Established Pa ent, Level 4
Office or other outpa ent visit for the evalua on and management of an established pa ent, which requires at least 2 of these 3 key
components: A detailed history; A detailed examina on; Medical decision making of moderate complexity. Counseling and/or coordina on
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the
problem(s) and the pa ent’s and/or family’s needs. Usually, the presen ng problem(s) are of moderate to high severity.

1.

Do you provide the service frequently enough to feel comfortable es ma ng service me?
Yes  Complete remainder of table

No  Skip to the next page, Section B

Indicate how o en you provide this service in each of the ways described below. Think about the me you, PAs, and NPs spend providing
the service, as well as the me spent by a PA or NP working with you.

2.
Thinking about all of the mes you provide this
service (99214), please es mate the % of me
you provide it in each of the following ways.

3.

4.

Your me (in minutes per service)

NP/PA’s me (in minutes per service)

An approximaƟon is fine.
Should sum to 100%

a. Without a PA or NP
b. With a PA or NP
providing assistance

Pre

Intra

%
%

c. Supervising a PA or NP
who provides substan al
independent care

%

Page 5 of 8

Post

Pre

Intra

Post

N/A

N/A

N/A

Sec on B
This sec on includes ques ons about your prac ce.
Please think about the office loca on where you spend the most direct pa ent care hours.
If you split your me equally, select the prac ce you have been with the longest.
B1.

Which of the following best describes the office loca on where you spend the most direct
pa ent care hours?
Solo practice  Skip to B4
Single specialty group
Multispecialty group
Medical school faculty practice
Hospital

B2.

How many full me equivalent (FTE) physicians are associated with this prac ce loca on?
Please answer thinking about the loca on where you spend the most of your direct pa ent care hours.
2 – 5 physicians
6 – 10 physicians
11 – 30 physicians
31 – 100 physicians
More than 100 physicians

B3.

How many of these FTE physicians prac ce primarily Cardiology, regardless of subspecialty? Please
es mate to the best of your ability.
Physicians

B4.

How many FTE nurse prac oners, physician assistants, and assistants-at-surgery prac ce in the
same specialty or department as you, at your primary loca on? Please es mate to the best of
your ability.
Nurse prac

oners, physician assistants, and assistants-at-surgery

Page 6 of 8

B5.

Approximately how many years have you been working in this se ng?
Years

B6.

Which of the following best describes the electronic health records (EHR) adoption status at your
primary practice location?
We do not have an EHR system.
We are not ac vely using an EHR system but we have one installed.
We are ac vely using an EHR system that was installed within the past 18 months.
We are ac vely using an EHR system that was installed more than 18 months ago.

B7.

What percent of the prac ce’s pa ents rely on the following sources for payment for the services
they receive? Please es mate to the best of your ability.
% Medicare (including Medicare Advantage health plans)
% Medicaid and other public sources

Sec on C
This sec on includes ques ons about you and your work style.
C1.

What is your age?
Less than 35 years of age
35 to 44 years of age
45 to 54 years of age
55 or older

C2.

Approximately how many years have you been prac cing Cardiology?
Years

Page 7 of 8

C3.

During a typical week, approximately how many total hours do you spend in all
medically related ac vi es? Medically related ac vi es are defined as me spent on administra ve
tasks, professional ac vi es, and direct pa ent care but not me spent on call while not trea ng
pa ents.
Less than 20 hours
20 to 39 hours
40 to 59 hours
60 hours or more

C4.

Approximately what percentage of this me is spent on direct pa ent care? Direct pa ent
care includes ac vi es such as seeing pa ents, performing surgery or procedures, telephone and email
communica ons with pa ents and their families, and me spent on pa ent record-keeping, pa entrelated office work, interpre ng tests and imaging, and travel me associated with direct pa ent care.
% of me spent on direct pa ent care

C5.

Which of the following describes your basic compensa on?
Fixed salary
Shift, hourly, or other time-based payment
Share of practice billings or workload (e.g. fee-for-service)
Other method, please describe:

C6.

Are you eligible to earn income through any type of bonus or incen ve plan? Mark yes if you receive
periodic adjustments, bonuses, returns on withholds, or any type of supplemental payments, either
from your prac ce or from health plans.
Yes
No

Thank you for completing this questionnaire.
Please check to see that all questions are answered.
Please mail these forms to us at the address below. A postage-paid envelope is provided.
Survey of Clinical Time, c/o Lourdes Suárez, 1009 Slater Road, Suite 120, Durham, NC 27703
phone: 1-877-754-6104

Page 8 of 8