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PubMedDate not supplied

Onychauxic dystrophic toenails requiring debridement in Medicare patients. Prevalence and anatomical distribution.

Six hundred twenty-nine Medicare patients were evaluated for the presence of onychauxic toenails that in the judgment of the examiners required reduction. Forty-two percent of this group had five or fewer toenails requiring reduction and 24.3% had six or more toenails requiring reduction. Statistics reported by a regional Medicare-contracted carrier for the years 1997 to 1999 showed that 95% of claims submitted for nail debridement were for six or more nails and 5% were for five or fewer nails. The 1999 Medicare Part B data listed the top 300 Current Procedural Terminology (CPT) foot-care codes in order of utilization. Code 11721 (debridement of six or more nails) was number one. National statistics from the Health Care Financing Administration in 1999 indicated approximately a 5:1 ratio in favor of CPT code 11721 (six or more nails). In contrast, this study found a ratio of 2:1 in favor of CPT code 11720 (five or fewer nails).

Aged↗
PubMed1993

Reimbursement for clinical flow cytometry testing.

Throughout the United States, reimbursement for new laboratory technology is not well understood by the clinicians and laboratory personnel who provide it. It is important to understand how new technology will be paid for in today's changing, more tightly controlled, health-care funding environment. For flow cytometry testing, specifically, this confusion is not just restricted to providers of the tests. The carriers from many states still list flow cytometry as "investigational", contrary to the 1988 HCFA ruling. Although the HCFA ruling is not subject to interpretation by state Medicare carriers, it is often up to the provider whose claims are being denied to educate the carrier concerning its mistake. When confronted with the appropriate evidence (sometimes including a phone call from the regional HCFA office), most carriers relent. It is critical to note that claims must be billed correctly. This means that approved ICD-9-CM codes must be used with the appropriate CPT-4 codes. If there is no prevailing rate established in the state or if it has been established prohibitively low, it will be necessary to lobby and educate the carrier in regard to the medical necessity of the testing, as well as justifying the cost. This can be done by providing the medical director of the carrier with all necessary patient information, laboratory reports, and scientific literature validating the use of the technology for each individual claim. It may also require submitting cost justification data supporting the request. The importance of the development of a good working relationship with one's local Medicare carrier cannot be overemphasized. This relationship is a critical component of establishing a fair and appropriate rate for the reimbursement of any test.

Aged↗
PubMed2002

Expert agreement in Current Procedural Terminology evaluation and management coding.

BACKGROUND: Available data suggest that physicians are accurate in approximately 55% of Current Procedural Terminology (CPT) evaluation and management (E/M) coding for their services. This accuracy is relative to observers' or auditors' assigned codes for these services, a group that has not been studied for their consistency in application of the CPT E/M coding guidelines. The purpose of this study was to determine the level of agreement of certified coding specialists in their application of CPT E/M coding guidelines. METHODS: Three hundred certified professional coding specialists randomly selected from the active membership of the American Health Information Management Association were sent 6 hypothetical progress notes of office visits along with a demographic survey. The study group assigned CPT E/M codes to each of the progress notes and completed the demographic survey. RESULTS: Coding specialists agreed on the CPT E/M codes for 57% of these 6 cases. The level of agreement for the individual cases ranged from 50% to 71%. Relative to the most common or consensus code, undercoding of established patients occurred more commonly than overcoding. In contrast, for new patient progress notes, overcoding relative to the consensus code was more common than undercoding. CONCLUSIONS: There is substantial disagreement among coding specialists in application of the CPT E/M coding guidelines. The results of this study are similar to results of prior studies assessing physician coding accuracy, suggesting that the CPT coding guidelines are too complex and subjective to be applied consistently by coding specialists or physicians.

Adult↗
PubMedDate not supplied

How to complete a medical insurance form.

The information submitted is knowledge accumulated over years of experience teaching dentists how to bill medical insurance. This is supplemented with a good number of personal expert witness testimonies in criminal and malpractice insurance cases. The objective is to prevent problems before they start with the prudent use of information. My experience in court testimony on these issues has shown me that there is an army of lawyers, insurance company fraud examiners, and dentists working for the aforementioned, just waiting for you to improperly use this method of insurance reimbursement. Use this only if you understand the nuances of what it is you are doing! For example, any procedure you bill to dental insurance using CDT-2 codes can be billed to medical insurance using medical insurance CPT-95 codes. The difference is that if the procedure is not a covered medical expense, it will not be paid by the medical insurance carrier. I strongly suggest that you do not fall into the trap of obfuscating these codes. There are a number of so-called insurance "gurus" teaching dentists how to write confusing and misleading operative reports so as to obtain reimbursement for procedures that normally would not be covered. I beseech you--please do not do it! The penalties are severe. You will experience a significant increase in payments from the medical insurance when procedures are submitted in the proper manner. More and more computerized dental insurance management programs are offering their clients the ability to automatically cross-code and submit dental/medical insurance claims. It is a recognized ability of dentists to do such. Billing responsibly is of the utmost importance.

Forms and Records Control↗
PubMed2005

Understand the "fine print" when selecting the correct codes for patient admissions from clinic to hospital.

How should a physician code and bill for services when a patient is seen in the clinic and then is directly admitted to the hospital? The correct answer is not as straightforward as it might at first seem because of needing to understand what amounts to the "fine print" in the Current Procedural Terminology (CPT) book code description. It also depends on whether or not the physician subsequently had face-to-face contact with the patient in the hospital. According to the CPT book, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g. physician's office) all evaluation and management services (E/M) provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission s/he provided in the other sites of service as well as in the inpatient setting." At first, this wording could lead physicians and coders to conclude that their only recourse is to "roll up" the level of service provided in the clinic with the additional documentation necessary to admit a patient to the hospital to determine the code for "Initial Hospital Care", CPT 99221-99223. However, it has been noted that the description in the CPT book under initial hospital care has "fine print" in the statement the "codes are used to report the first hospital inpatient encounter with the patient by the admitting physician." "Encounter" is commonly understood to mean a "face to face" encounter between the physician and patient in the hospital setting. But, what if the physician does not go to the hospital to see the patient on the same date that s/he saw the patient in the clinic? Because a face to face encounter in the hospital did not occur, it would be inappropriate to use any of the "Initial Hospital Care" CPT 99221-99223 codes. Rather, the services of the clinic visit should be billed as "new" or "established" patient office visit on the date seen and the initial hospital service would be billed on a following date when the physician actually sees the patient in the hospital setting.

Ambulatory Care Facilities↗
PubMed2003

Validation of data collection for the HEDIS performance measure on chlamydia screening in an MCO.

OBJECTIVE: To determine the validity of calculating the chlamydia Health Plan Employer Data and Information Set (HEDIS) measure using administrative data available in a mixed-model managed care organization (MCO). STUDY DESIGN: Retrospective cohort study. METHODS: A review of International Classification of Diseases, Ninth Revision (ICD-9), Current Procedural Termin-ology (CPT), Healthcare Common Procedure Coding System (HCPCS), and National Drug Code codes and electronic laboratory files in 1998 and a medical chart review to validate sexual activity and chlamydia testing codes specified by the National Committee for Quality Assurance (NCQA) in 1999 for the chlamydia HEDIS 2000 measure. RESULTS: Fewer than 25% of female enrollees with laboratory evidence of a chlamydia test had a CPT code for chlamydia testing as specified by the NCQA. Non-pathogen-specific test codes instead of NCQA-specified codes were used in 1998 to code chlamydia tests. By incorporating electronic laboratory data into the automated claims-generating process, all chlamydia tests performed at staff-model clinics were coded. Use of pharmacy dispensing data to identify contraceptive prescriptions increased the proportion of enrollees classified as sexually active by 4% to 5% vs documentation of sexual activity using ICD-9, CPT, and HCPCS codes only. CONCLUSIONS: The MCO quality assurance specialists examining chlamydia testing rates under HEDIS may want to evaluate chlamydia testing coding practices in their MCOs to determine whether simple changes in coding practices may present a more accurate picture of actual testing practices. The proportion of female enrollees classified as sexually active using different data available in the staff and network models varied only slightly.

Adolescent↗
PubMedDate not supplied

E/M coding problems plague physicians, coders.

As the government turns its high beams on fraudulent billing, physician E/M coding is raising questions. With several studies spotlighting the difficulty physicians have in applying CPT E/M codes, the authors wanted to know if credentialed coders had the same problem. Here's what they found.

Diagnostic Services↗
PubMed2002

Valuing neurosurgery services: part II. The interdependence of Current Procedural Terminology and federal Medicare payment policy.

Current Procedural Terminology (CPT) policies for coding of medical procedures and services are adopted by the American Medical Association CPT editorial panel. Since institution of the Medicare Fee Schedule in 1992, the Medicare budget neutrality rule has strongly influenced CPT policies for the coding of additions or modifications. The Centers for Medicare and Medicaid Services Medicare program policies, particularly payment limits, influence code modification strategies and CPT editorial panel processes.

Fee Schedules↗
PubMed1999

Ambulatory patient classifications and the regressive nature of Medicare reform: is the reduction in outpatient health care reimbursement worth the price?

PURPOSE: To evaluate the impact of the proposed Ambulatory Patient Classification (APC) system on reimbursement for hospital outpatient Medicare procedures at the Massachusetts General Hospital (MGH) Department of Radiation Oncology. METHODS AND MATERIALS: Treatment and cost data for the MGH Department of Radiation Oncology for the fiscal year 1997 were analyzed. This represented 66,981 technical procedures and 41 CPT-4 codes. The cost of each procedure was calculated by allocating departmental costs to the relative value units (RVUs) for each procedure according to accepted accounting principles. Net reimbursement for each CPT-4 procedure was then calculated by subtracting its cost from the allowed 1998 Boston area Medicare reimbursement or from the proposed Boston area APC reimbursement. The impact of the proposed APC reimbursement system on changes in reimbursement per procedure and on volume-adjusted changes in overall net reimbursements per procedure was determined. RESULTS: Although the overall effect of APCs on volume-adjusted net reimbursements for Medicare patients was projected to be budget-neutral, treatment planning revenues would have decreased by 514% and treatment delivery revenues would have increased by 151%. Net reimbursements for less complicated courses of treatment would have increased while those for treatment courses requiring more complicated or more frequent treatment planning would have decreased. Net reimbursements for a typical prostate interstitial implant and a three-treatment high-dose-rate intracavitary application would have decreased by 481% and 632%, respectively. CONCLUSION: The financial incentives designed into the proposed APC reimbursement structure could lead to compromises in currently accepted standards of care, and may make it increasingly difficult for academic institutions to continue to fulfill their missions of research and service to their communities. The ability of many smaller, low patient volume, high Medicare mix hospital-based radiation oncology departments to continue to deliver their current level of care could be compromised. APC reform may carry monetary and opportunity costs which far outweigh its apparent savings. As payment systems continue to place pressure on operating margins, it becomes even more critical that both academic and community radiation oncology practices know the cost of providing services.

Ambulatory Care↗
PubMed1995

Depressive disorders: treatment patterns and costs of treatment in the private sector of the United States.

The purpose of this paper is to examine the treatment patterns and costs of treatment for depressive disorders in the private sector of the United States. Based on the 1987-1989 calendar year MEDSTAT claim data, 40,898 patients were identified with a principal diagnosis of depressive disorder. Among a list of CPT-4 code procedures, individual psychotherapy had the highest frequency of usage followed by individual visits. Compared to individual psychotherapy, group/family psychotherapy had a much lower frequency of usage. Very few diagnostic episodes had laboratory work. In inpatient settings, costs of physician procedures and laboratory services were 2 times greater for patients with major depression or bipolar disorder than for patients with depression not otherwise specified (NOS) or dysthymic disorder. As expected, costs varied widely per episode. As the severity of illness increased, the cost variation became wider.

Adolescent↗
PubMed2004

Trends in utilization: has extremity MR imaging replaced diagnostic arthroscopy?

OBJECTIVE: To examine the relative change in utilization of magnetic resonance (MR) imaging of the extremities versus diagnostic and therapeutic arthroscopy. DESIGN AND PATIENTS: Using the 1993, 1996, and 1999 nationwide Medicare Part B databases, utilization rates (per 100000) were determined for upper and lower extremity MR imaging, diagnostic arthroscopy and therapeutic arthroscopy using CPT-4 codes. Utilization of extremity MR imaging was compared with that of diagnostic and therapeutic arthroscopy in 10 geographic regions of the United States and tracked over time. RESULTS: Combined lower and upper extremity MR imaging utilization per 100000 increased from 393 to 1056 in 1999 (+168.7%). Utilization of diagnostic arthroscopy of the extremities decreased from 18 in 1993 to 8 in 1999 (-55.6%); therapeutic arthroscopy rates increased from 461 in 1993 to 636 in 1999 (+40.0%). Specifically, from 1993 to 1999, utilization of lower extremity MR imaging increased from 270 to 661 (+144.8%). Utilization of diagnostic arthroscopy of the knee over the same time period decreased from 11 to 5 (-54.5%); therapeutic arthroscopy increased from 394 to 501 (+27.2%). Similarly, utilization rates for upper extremity MR imaging increased from 123 to 395 (+221.1%). Utilization of diagnostic arthroscopy of the shoulder over the same time period decreased from 7 to 2 (-71.4%); therapeutic arthroscopy increased from 44 to 104 (+136.4%). No specific geographic trends were ascertained. CONCLUSION: The utilization of MR imaging of the extremities has markedly increased from 1993 to 1999. During the same time period the utilization of diagnostic arthroscopy has decreased and that of therapeutic arthroscopy has increased. These findings support the hypothesis that there is increased reliance of clinical practitioners on the diagnostic information provided by MR imaging in preoperative clinical decision-making.

Aged↗
PubMed2005

Changes in the proportion and volume of care provided to children by generalists and subspecialists.

OBJECTIVE: To assess whether primary care physicians, via referrals or other mechanisms, are now providing proportionally less care for children with specific common diagnoses, thus driving greater demand for specialist services. STUDY DESIGN: Secondary data analysis (1993-2001) from one of the largest commercial healthcare organizations in the United States. Evaluation and management (E/M) common procedural terminology (CPT) visit codes and International Classification of Diseases (ICD) codes pertaining to asthma, constipation, headache, and heart murmurs were selected. Visits were then assigned to the specialty of physician providing care. Significant differences between and among categories of physicians were tested using logistic regression. RESULTS: Overall, pediatrician generalists and specialists provided a greater proportion of E/M visits to children in 2001 than in 1993, compared with nonpediatrician providers. However, although the absolute increase in the proportion of all E/M visits by children <18 years of age to pediatrician generalists was greater than that of pediatrician subspecialists (4.77% vs 0.69%; P <.0001), the relative increase was much smaller for the generalists (8.9% vs 19.7%; P <.0001). Findings were consistent for most of the specific diagnoses examined. CONCLUSIONS: The increases in both the proportion and number of visits made to specialists has not been accompanied by a decrease in visits to generalists.

Asthma↗
PubMed2001

Outcome and resource use associated with myomectomy.

OBJECTIVE: To evaluate the outcomes and cost of myomectomy through retrospective claims data analysis. METHODS: The study was performed using a retrospective database of private insurance claims from 1995 to 1997. Records were selected for analysis based on the presence of ICD-9-CM procedure and/or CPT-4 codes associated with myomectomy. In addition, diagnosis of uterine leiomyoma and related symptoms for these patients were confirmed through ICD-9-CM diagnosis codes. Inpatient, outpatient, and physician costs were estimated. All cost data were converted into 1997 dollars. RESULTS: A total of 4394 women, between the ages of 14 and 70, were available for analysis. Of these, 3305 were classified by type of myomectomy procedure, and complete data were available on 820 at 1 year and 236 at 2 years. Abdominal myomectomies were the most common procedures, followed by hysteroscopic and laparoscopic myomectomies. Conversion to a more invasive procedure occurred in 5.4% of the patients. The rate of additional surgeries was 8.3% in 6 months, 10.6% in 1 year, and 16.5% in 2 years. Overall cost increased from an initial 6,737 dollars per patient to 7,575 dollars in 1 year and to 8,001 dollars in 2 years. CONCLUSION: The repeat procedures required after the initial myomectomy add significantly to total cost and highlight the importance of assessing post-procedure health care use. This comprehensive analysis facilitates the systematic evaluation of myomectomy with current and emerging alternative treatments for uterine leiomyomas.

Adolescent↗
PubMed1996

Assessment of appropriateness of cataract surgery at ten academic medical centers in 1990.

PURPOSE: To develop criteria for the appropriateness of cataract surgery (extracapsular cataract extraction or phacoemulsification with planned implantation of a posterior chamber intraocular lens) and to apply these criteria to patients from ten academic medical centers. METHODS: The study is a retrospective case series from ten academic medical centers. One thousand one hundred thirty-nine patients who had had cataract surgery in 1990 at the medical centers were selected randomly. Patients, identified by specific ICD-9-CM or CPT-4 codes, had no other ocular surgery performed at the same time as cataract surgery. Rates of inappropriate, uncertain, appropriate, and appropriate and crucial surgeries were determined by application of the criteria established by a multidisciplinary expert panel. RESULTS: Approximately 2% of the procedures were classified as inappropriate, after adjusting for missing or nonspecific visual function by use of discriminant analysis. Ninety-one percent of the procedures were classified as appropriate (52%) or appropriate and crucial (39%). Seven percent were designated as uncertain, either due to a median rating in the uncertain range or to disagreement in ratings among the panelists. Significant variation occurred in the results among the different institutions: inappropriate surgeries ranged from 0% to 4%, uncertain from 1% to 14%, appropriate from 35% to 66%, and appropriate and crucial from 21% to 62% (P=0.02). CONCLUSION: A small percentage of cataract surgeries was performed at these ten academic medical centers for inappropriate indications using the study criteria. Given the large number of cataract surgeries performed annually, the small percentage of uncertain and inappropriate surgeries may translate into a large number of surgeries performed for less than appropriate or appropriate and crucial indications. Significant variation existed among the institutions in the distribution of appropriate and crucial and appropriate compared with uncertain and inappropriate surgeries.

Academic Medical Centers↗
PubMed1999

Do interventional radiologists pose a significant threat to the practice of vascular surgery?

PURPOSE: Vascular surgeons have become concerned recently about perceived threats to their practices posed by the growth of interventional radiology. The authors studied nationwide 1996 Medicare Part B procedure data to determine the seriousness of these threats. MATERIALS AND METHODS: The national Health Care Financing Administration (HCFA) Physician/Supplier Procedure Summary Master File for 1996 was searched. Two hundred thirteen distinct Current Procedural Terminology (CPT-4) codes were identified for therapeutic surgical and percutaneous interventional procedures performed to treat noncardiac vascular diseases. For each code, determination was made of total volume, specialty of the physician providers, and Medicare Part B reimbursement dollars paid to the providers as professional fees. In view of the conflicts among various specialties over peripheral vascular interventions, the authors also determined the percentages of these procedures performed by radiologists, surgeons, cardiologists, and other physicians. RESULTS: A total of 759,548 noncardiac therapeutic vascular procedures (operations or percutaneous interventions) were performed during 1996 in patients receiving Medicare benefits. Radiologists performed 135,103 (17.8%) of these procedures but received only 10.4% of professional reimbursements. By contrast, surgeons performed 510,871 (67.3%) procedures, but received 78.0% of professional reimbursements. Cardiologists performed 4.7% of procedures and other specialists performed the remaining 10.3%. Radiologists performed 75.5% of percutaneous transluminal angioplasties, the majority of thrombolysis procedures, stent placements, and portal decompression procedures, and approximately half of inferior vena cava interruptions. Cardiologists performed 12.6% of percutaneous transluminal angioplasties, surgeons performed 6.3%, and other specialists performed 5.6%. CONCLUSIONS: In terms of overall physician workload and professional reimbursements paid for invasive treatment of all types of noncardiac vascular disease, surgeons predominate and do not appear to be seriously threatened by interventional radiologists. Radiologists perform three-fourths of noncardiac percutaneous transluminal angioplasties and a majority of other percutaneous interventional therapies for vascular disease, but some inroads have been made by cardiologists and surgeons, particularly the former.

Aged↗
PubMed1987

An access-oriented negotiated fee schedule. The Caterpillar experience.

This paper describes the system used by Caterpillar Corporation (CAT) in Peoria, Illinois, to reimburse surgeons. The CAT system assures access for Caterpillar employees and their families to a selection of qualified surgeons, while achieving cost savings through improvements in processing of surgical claims and negotiation of selected fees. CPT-4 codes are recorded for greater accuracy, when indicated, surgical services that have been incorrectly unbundled are rebundled, and the appropriateness of surgical assistant charges is reviewed. A "degree of difficulty" relative value scale (DODRVS) of surgical services is periodically revised as technology changes. The DODRVS multiplied by a regional factor, determined by local market research, establishes the fee that CAT will pay the surgeon. Balance billing is permitted if the patient (1) is informed in advance by the surgeon that the fee will be higher than CAT will pay, and (2) knows that the service can be obtained from other local surgeons who will accept the CAT fee. The goal of the CAT method of surgeon reimbursement is to gain physician support for an access-oriented, market-driven negotiated fee schedule. Compared with a resource-based relative value scale RBRVS) methodology, the CAT system is not formula-driven and depends on physician acceptance.

Fee Schedules↗
PubMedDate not supplied

Incidence of inpatient surgeries in children and young adults with childhood orthopaedic diagnoses.

The incidence of orthopaedic surgery for young people with childhood onset of orthopaedic disabilities is not well documented. This study tabulated that incidence in the past two decades in California. Trauma, tumors, and hand surgery were not included in the study. Common pediatric orthopaedic diagnoses by ICD-9 code requiring CPT orthopaedic surgical procedures were tabulated in three years: 1983, 1990, and 1999. The most common procedures in each of these years studied were, in order of incidence, scoliosis, congenital hip problems, slipped femoral capital epiphyses, and clubfeet. The incidence of surgery for scoliosis and slipped femoral capital epiphyses increased over the past two decades. These data should be helpful in planning for future inpatient services for orthopaedically handicapped children.

Adolescent↗