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PubMed2002

The feasibility of paper-based Tracking Codes and electronic medical record systems to monitor tobacco-use assessment and intervention in an Individual Practice Association (IPA) Model health maintenance organization (HMO).

Despite evidence of its effectiveness, tobacco cessation is not systematically addressed in routine healthcare settings. Its measurement is part of the problem. A pilot study was designed to develop and implement two different tobacco tracking systems in two independent primary care offices that participated in an IPA Model health maintenance organization in Portland, Oregon. The first clinic, which utilized a paper-based charting system, implemented CPT-like tracking codes to measure and report tobacco-cessation activities, which were eventually included in the managed-care organization's (MCO) claims database. The second clinic implemented an electronic tracking system based on its computerized electronic medical record (EMR) charting system. This paper describes the pilot study, including the processes involved in building provider acceptance for the new tracking systems in these two clinics, the barriers and successes encountered during implementation, and the resources expended by the clinics and by the MCO during the pilot. The findings from the 3-month implementation period were that documentation of tobacco-use status remained stable at 42-45% in the paper-based clinic and increased from 79% to 88% in the EMR clinic. This pilot study demonstrated that Tracking Codes are a feasible preventive-care tracking system in paper-based medical offices. However, high levels of effort and support are needed, and a critical mass of insurers and health plans would need to adopt Tracking Codes before widespread use could be expected. Results of the EMR-based tracking system are also reviewed and discussed.

Costs and Cost Analysis↗

PubMed2005

Under-recognition of polyneuropathy in persons with diabetes by nonphysician electrodiagnostic services providers.

OBJECTIVE: Healthcare providers commonly refer patients to physiatrists and neurologists for electrodiagnostic testing when they have symptoms suggestive of a peripheral nerve disorder. Published practice guidelines specify that electrodiagnostic medicine consultants should possess special neurologic and procedural training in this area. We recently found that despite these practice guidelines, physical therapists, chiropractors, and podiatrists perform 17% of electrodiagnostic studies in the United States. These findings prompted the current investigation examining electrodiagnostic care across different providers for an important target population-persons with diabetes. DESIGN: A retrospective cohort of patients with diabetes who underwent electrodiagnostic testing in 1998 was identified in the MarketScan Commercial Claims & Encounters Database (The MEDSTAT Group) using CPT and ICD9CM codes. This database represents the healthcare claims for 16 million Americans in private and employer-based health plans. The outcome of interest was the rate of polyneuropathy identification across different providers, controlling for patient characteristics. RESULTS: There were 6381 electrodiagnostic encounters for persons with diabetes in 1998. Polyneuropathy identification rates were highest for physiatrists, osteopathic physicians, and neurologists (12.5%, 12.2%, and 11.9%, respectively). Podiatrists and physical therapists identified 2.4% and 2.1%, respectively, as having polyneuropathy-rates about one sixth that of physiatrists and neurologists despite controlling for casemix differences. Nonphysician providers who did not recognize polyneuropathy performed almost exclusively EMG testing (>90%) at the expense of nerve conduction studies. CONCLUSIONS: This study raises concerns about the quality of electrodiagnostic testing by nonphysician providers for persons with diabetes. These results should prove useful for physicians, third-party payers, and health policy makers when confronting issues related to provision of electrodiagnostic services.

Adolescent↗

PubMed1994

A computerized geriatric assessment designed for use in primary care physicians' offices.

Comprehensive geriatric assessments have generally been recognized as beneficial for frail elderly patients. However, the complexity of these evaluations has usually required that they be performed in a multidisciplinary setting. Staffing requirements, time commitment, new skill requirements, and reimbursement problems serve as impediments for primary care physicians performing these examinations. Computer technology may be the solution to these problems. A software program has been developed which allows primary care physicians to perform a sophisticated functional assessment on an outpatient basis without the use of a multidisciplinary team. Problems are identified by the computer-assisted protocol and patients are referred for appropriate management. Thus, the physician maintains a primary role in case management. The program is cost effective because it does not require additional staff to operate it and it effectively uses CPT and ICD9 coding.

Aged↗

PubMed1997

Strabismus surgery among aged medicare beneficiaries.

OBJECTIVES: The purpose of this study was to investigate the incidence of strabismus surgery among aged patients in the United States. METHODS: The Medicare Part B claims experience (physician professional fee billing) for 1995 was reviewed for the number of times each strabismus surgical procedure recognized in Physicians' Current Procedural Terminology (CPT) was performed. To determine the indications for the procedures that were performed, a 5% sample of claims was reviewed for the pertinent International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic codes. RESULTS: There were 27 million aged Medicare beneficiaries eligible for Part B benefits in 1995 in a fee-for-service setting. During that year physicians reported 9497 strabismus physician services. These represented 6585 separate procedures (CPT codes 67311 to 67343) and 277 botulinum toxin (Botox) injections for strabismus (CPT 67345) performed during 1995. Sixty-nine percent of the surgical procedures were for horizontal correction and 28% were for vertical correction. Adjustable sutures were used for only 1240 cases (1 9%). The add-on procedural code for reoperation surgery or surgery in the presence of restriction of the extraocular muscles was used in just 930 cases (14%). The most common diagnosis for horizontal surgery was exotropia. Paralytic strabismus and thyroid disease were identified for 17% of cases. Three percent of the diagnoses were inappropriate for the procedures performed and may have been reported in error. CONCLUSIONS: These data confirm a very low incidence of strabismus surgical procedures (2/10,000) and injections (1/100,000) among aged Medicare beneficiaries. The strabismus surgery was most often performed to repair a horizontal deviation. The adjustable suture technique was used infrequently. These data may be extrapolated into the future to aid in determining the strabismus services that will be needed early in the next century.

Aged↗

PubMed2002

Do third-party plans really pay for CVS care?

Until specific CPT and ICD-9 codes are created and approved for CVS, and until there is uniform agreement that CVS is a true medical anomaly (or not), each practitioner will have to decide on how to bill for the signs and symptoms of Computer Vision Syndrome. If the practitioner chooses to view CVS as a medical problem, then the same guidelines and rules for all other patients should be followed with appropriate documentation using CPT and ICD-9 coding. If the practitioner chooses to consider CVS solely as an optical problem, this is a "noncovered" service and the patient or any applicable optical plan will be responsible for payment. One final note: each practitioner who tests for CVS will also have to determine if there is a separate fee for CVS testing. If the practitioner considers CVS to be a medical problem, it may be applicable to include testing for Computer Vision Syndrome as an incidental test to the medical office visit. If the practitioner chooses to consider CVS to be purely an optical problem, it may be appropriate to add an appropriate charge to the noncovered examination. Whatever the decision is, there must be consistency from patient to patient.

Computers↗

PubMed2005

Carotid stenting.

Coding personnel should be aware of the new CPT guidelines for reporting carotid and vertebral stent placement. Payors' billing requirements for these procedures vary, and it is important to determine before billing whether the payor will accept the applicable CPT category I or III code or whether an unlisted code must be reported. Coding guidancefor these procedures will likely continue to evolve in thenear future.

Carotid Stenosis↗

PubMed1996

Review paper: coding systems in health care.

Computer-based patient data which are represented in a coded form have a variety of uses, including direct patient care, statistical reporting, automated decision support, and clinical research. No standard exists which supports all of these functions. Abstracting coding systems, such as ICD, CPT, DRGs and MeSH fail to provide adequate detail, forcing application developers to create their own coding schemes for systems. Some of these schemes have been put forward as possible standards, but they have not been widely accepted. This paper reviews existing schemes used for abstracting, electronic record systems, and comprehensive coding. It also discusses the remaining impediments to acceptance of standards and the current efforts to overcome them, including SNOMED, the Gabrieli Medical Nomenclature, the Read Clinical Codes, GALEN, and the Unified Medical Language System (UMLS).

Abstracting and Indexing↗

PubMed2002

Coding and billing for gastrointestinal endoscopy.

The complexities associated with the coding, billing, and reimbursement process seem to increase daily. Keeping abreast of the changes in this environment is, to say the least, a challenge. To succeed in today's billing environment the gastroenterologist should surround his or her practice with staff, resources, and education. Experienced skilled staff, preferably a certified professional coder should be employed. Certified coders bring advanced coding skills to ones practice, which allows increased proficiency with the coding and billing process. Provide the necessary resources for staff. Current coding material is crucial to the financial success of the practice. CPT-4, ICD-9, and Correct Coding Guide are the bare basics of the resource material available to staff. Maintaining a library of resource material (i.e., Medicare bulletins, managed care newsletters, and so forth) aids the staff with the necessary tools to carry out their duties. In addition, specific gastroenterology coding subscriptions are available to assist in staying ahead of the ever-changing billing and coding environment. Continuing education in the billing and coding process for both the physician and staff is essential. Numerous workshops are offered periodically. It is imperative that staff attends all Medicare-sponsored workshops in addition to gastroenterology-specific coding seminars. More and more physicians are now aware of their responsibility in the billing process and have begun to participate in the coding education along with their staff. This is a significant indicator of a physicians' intent to have a compliant and financially successful practice.

Cost-Benefit Analysis↗

PubMed2006

The incidence of repeat uterine surgery following myomectomy.

OBJECTIVE: To determine the incidence of subsequent leiomyoma surgery following myomectomy in a population-based cohort. METHODS: All women, ages 20-75 years, enrolled in a large HMO in Washington State, identified by CPT and ICD-9 codes as having a myomectomy between January 1, 1993, and December 31, 2002, were eligible for the study. The follow-up period was 0.1-11 years. Automated enrollment and inpatient, outpatient, pathology, and procedure data were linked. Age-adjusted hazard ratios (HR) and 95% confidence intervals (CI) using Cox proportional hazard models, age-specific Kaplan Meier estimates of cumulative risk, and incidence of uterine surgery after myomectomy were calculated. RESULTS: Among 628 eligible women, 127 (21.8%) had a second surgery, 95 (74.8%) of which were hysterectomies. The cumulative incidence of a second surgery was 23.5% at 5 years and 30% at 7 years. During 2766.5 woman-years of follow-up, the annual incidence of a subsequent myoma surgery was 4.6%. Compared with women aged 40-44, women >or=50 had a 50% decreased risk for subsequent surgery (HR = 0.5, 95% CI 0.3-0.9). CONCLUSIONS: The incidence of subsequent surgery for leiomyomas following myomectomy is high, almost 5% per year.

Adult↗

PubMed2000

Measuring contributions to the clinical mission of medical schools and teaching hospitals.

This is the final report of a panel convened as part of the Association of American Medical College's (AAMC's) Mission-based Management Program to examine the use of metrics (i.e., measures) in assessing faculty and departmental contributions to the clinical mission. The authors begin by focusing on methods employed to estimate clinical effort and calculate a "clinical full-time equivalent," a prerequisite to comparing productivity among faculty members and departments. They then identify commonly used metrics, including relative-value units, total patient-care gross charges, total net patient fee-for-service revenue, total volume per CPT (current procedural terminologies) code by service category and number of patients per physician, discussing their advantages and disadvantages. These measures reflect the "twin pillars" of measurement criteria, those based on financial or revenue information, and those based on measured activity. In addition, the authors urge that the assessment of quality of care become more highly developed and integrated into an institution's measurement criteria. The authors acknowledge the various ways users of clinical metrics can develop standards against which to benchmark performance. They identify organizations that are sources of information about external national standards, acknowledge various factors that confound the interpretation of productivity data, and urge schools to identify and measure secondary service indicators to assist with interpretation and provide a fuller picture of performance. Finally, they discuss other, non-patient-care, activities that contribute to the clinical mission, information about which should be incorporated into the overall assessment. In summary, the authors encourage the use of clinical productivity metrics as an integral part of a comprehensive evaluation process based upon clearly articulated and agreed-upon goals and objectives. When carefully designed, these measurement systems can provide critical information that will enable institutional leaders to recognize and reward faculty and departmental performance in fulfillment of the clinical mission.

Efficiency, Organizational↗

PubMed1996

Performance of neuroradiologic examinations by nonradiologists.

PURPOSE: To determine the level of participation by nonradiologists in performing neuroradiologic examinations. MATERIALS AND METHODS: Medicare part B claims data from fiscal year 1992 were analyzed for CPT (current procedural terminology) codes related to computed tomography (CT) and magnetic resonance (MR) imaging of the brain, head and neck, and spine, as well as myelography, angiography, and diskography. Data were tabulated by place of service (hospital-based vs freestanding imaging centers) and by medical specialty. RESULTS: Among 363,224 Medicare claims for CT and MR imaging of the brain, head and neck, and spine, 91% of the examinations were performed in hospitals and 9% in offices or freestanding centers; 98% of studies were interpreted by a radiologist. The largest share of radiology billing by nonradiologists was from office-based or freestanding imaging centers (9%), versus 2% at hospital-based facilities. CONCLUSION: Radiologists perform the vast majority of neuroradiologic examinations. Most neuroradiologic examinations performed by nonradiologists are from neurologists at freestanding/office-based imaging centers.

Angiography↗

PubMedDate not supplied

Resource use and patient care associated with chronic kidney disease in a managed care setting.

OBJECTIVE: To describe the resource utilization and care of chronic kidney disease (CKD) patients in a managed care plan. METHODS: This was a retrospective claims analysis of a nationwide managed care medical and pharmacy database from September 1, 1998, to July 31, 2001. Twenty-seven health plans in 19 states distributed across the Northeast, Southeast, Midwest, and Southwest United States were represented in this analysis. CKD patients were identified using ICD-9 CM, CPT-4, and HCPCS codes indicative of dialysis. Patients continuously enrolled for at least 6 months before and 3 months after an initial dialysis event were included in the study. Health care charges and associated clinical information were assessed during 3 time periods: predialysis was from the sixth through the second month before initial dialysis, peridialysis was 30 days before and 30 days after initial dialysis, and postdialysis was the second and third month after initial dialysis. The main outcome measures were total health care charges, primary diagnoses, and diagnosis- related groups (DRGs). RESULTS: The per-patient-per-month charges were 4,265 dollars in the predialysis period (average for 5 months), 35,292 dollars in the peridialysis period (average for 2 months), and 15,399 dollars in the postdialysis period (average for 2 months). The most common primary diagnosis categories during all time periods were chronic renal failure and congestive heart failure. Similarly, the most common DRGs were related to renal and heart failure. A total of 38.2% of patients did not have an initial nephrologist visit until the first dialysis event. Treatments with nutritional supplements and medications such as angiotensin-converting enzyme inhibitors and erythropoietin were found to be suboptimal. CONCLUSION: CKD patients generate significant medical charges during the predialysis period and after initiation of dialysis. Further investigations are warranted to assess the impact of active management of CKD patients on CKD-related health care expenditures in kidney disease.

Adolescent↗

PubMed2002

Structural and functional genomics of the CPT1B gene for muscle-type carnitine palmitoyltransferase I in mammals.

Muscle-type carnitine palmitoyltransferase I (M-CPT I) is a key enzyme in the control of beta-oxidation of long-chain fatty acids in the heart and skeletal muscle. Because knowledge of the mammalian genes encoding M-CPT I may aid in studies of disturbed energy metabolism, we obtained new genomic and cDNA data for M-CPT I for the human, mouse, rat, and sheep. The introns of these compact genes are 80% (mouse versus rat) and 60% (mouse versus human) identical. Sheep and goat, but not cow, pig, rodent, or human promoter sequences contain a short interspersed repeated sequence (SINE) upstream of highly conserved regulatory elements. These elements constitute two promoters in humans, sheep, and mice, and, contrary to previous reports, there is a second promoter in rats as well. Thus, the transcriptional organization of these genes is more uniform than previously supposed, with interspecies differences in the 5'-ends of the mRNAs reflecting differences in splicing; only in humans extensive splicing and splice variation is found in the 5'- and 3'-untranslated regions. In the mouse, intron retention was detected in heart, muscle, and testes and may indicate an additional mechanism of regulation of M-CPT I expression. Splice variation in the coding region was previously proposed to lead to expression of CPT I enzymes with altered malonyl-CoA sensitivity (Yu, G. S., Lu, Y. C., and Gulick, T. (1998) Biochem. J. 334, 225-231). However, when expressed in the yeast Pichia pastoris, none of three earlier described splice variants had CPT I activity. Therefore, the involvement of splice variation of M-CPT I in the modulation of malonyl-CoA inhibition of fatty acid oxidation may be less relevant than hitherto assumed.

3' Untranslated Regions↗

PubMed2006

Evaluation and management codes: from current procedural terminology through relative update commission to Center for Medicare and Medicaid Services.

BACKGROUND: Physicians should have a working knowledge of the process by which patient care codes are created and subsequently assigned values. The Society of Critical Care Medicine has representatives on the national committees that focus on code creation and definition and on assignment of relative value units. In addition, a better understanding of documentation requirements and the audit process will facilitate improved compliance and minimize liability. DISCUSSION: The authors discuss the current procedural terminology (CPT) process for defining care codes and the relative update commission (RUC) process for assigning values to those codes, with each code assigned a separate value in three separate categories. Steps for managing any concern or dispute about billing, denials, or an audit are subsequently addressed. Tenets of proper documentation are discussed, and some future developments are identified that are likely to affect critical care. CONCLUSION: Knowledge of the procedures by which care codes are defined and valued is necessary for using these codes properly, as well as for addressing needs unmet by existing codes. Preventing audits is the best approach to proper coding and billing, and documentation is key.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed2000

HCFA's final rule on APCs is out: ED managers can breathe sighs of relief.

The final rule on ambulatory payment classifications (APCs) for outpatient services from the Health Care Financing Administration (HCFA) was published in the April 7, 2000, Federal Register, with a July 1, 2000, implementation date. EDS might receive increased reimbursement for services under APCs, in sharp contrast to previous predictions of a 15% decrease in reimbursement. Instead of combining CPT and ICD-9-CM coding for clinic and emergency visits APCs, HCFA has assigned three APCs for the emergency department and a fourth APC for critical care. There is no APC for a medical screening exam, which could improve reimbursement. There is no separate APC for observation services, which means no additional payment will be given. You can continue to use your current charge structure and correlate present levels of service with the appropriate CPT visit level. You will have to "unbundle" visit levels to list nursing and physician procedures separately as specific line items.

Ambulatory Care↗

PubMedDate not supplied

The content coverage of clinical classifications. For The Computer-Based Patient Record Institute's Work Group on Codes & Structures.

BACKGROUND AND OBJECTIVE: Patient conditions and events are the core of patient record content. Computer-based records will require standard vocabularies to represent these data consistently, thereby facilitating clinical decision support, research, and efficient care delivery. To address whether existing major coding systems can serve this function, the authors evaluated major clinical classifications for their content coverage. METHODS: Clinical text from four medical centers was sampled from inpatient and outpatient settings. The resultant corpus of 14,247 words was parsed into 3,061 distinct concepts. These concepts were grouped into Diagnoses, Modifiers, Findings, Treatments and Procedures, and Other. Each concept was coded into ICD-9-CM, ICD-10, CPT, SNOMED III, Read V2, UMLS 1.3, and NANDA; a secondary reviewer ensured consistency. While coding, the information was scored: 0 = no match, 1 = fair match, 2 = complete match. RESULTS: ICD-9-CM had an overall mean score of 0.77 out of 2; its highest subscore was 1.61 for Diagnoses. ICD-10 scored 1.60 for Diagnoses, and 0.62 overall. The overall score of ICD-9-CM augmented by CPT was not materially improved at 0.82. The SNOMED International system demonstrated the highest score in every category, including Diagnoses (1.90), and had an overall score of 1.74. CONCLUSION: No classification captured all concepts, although SNOMED did notably the most complete job. The systems in major use in the United States, ICD-9-CM and CPT, fail to capture substantial clinical content. ICD-10 does not perform better than ICD-9-CM. The major clinical classifications in use today incompletely cover the clinical content of patient records; thus analytic conclusions that depend on these systems may be suspect.

Decision Support Techniques↗

PubMed1999

Linked insurance-tumor registry database for health services research.

OBJECTIVE: Breast cancer screening and treatment data are often limited to restricted populations, including women older than 65 years old. The goal of this project was to develop procedures to link tumor registry and insurance claims databases on women younger than 65 years old with breast cancer and to assess the accuracy and validity of the linked dataset. METHODS: Iowa Cancer Registry (ICR) and Wellmark Blue Cross/Blue Shield of Iowa (BC/BS) membership files of women with incident in situ or invasive breast cancer from 1989 to 1996 were linked. An automated deterministic match was followed with visual inspection from three independent reviewers applying a matching protocol. Matched and overall registry data were compared to assess population representativeness. Claims from BC/BS for incident cases during 1994 were examined for coding of a recent breast cancer diagnosis or treatment. RESULTS: The final dataset included 4,397 matched cases of patients aged 21 years and older from 1989 to 1996. The sociodemographic and tumor characteristics of the ICR population younger than 65 years old (n = 7,469) with breast cancer or carcinoma in situ were nearly identical with those of the matched patients younger than 65 years old (n = 3,449). Nearly all (96%) of the 445 matched incident cases in 1994 had claims data (CPT, DRG, or ICD-9 code) indicative of breast cancer. Treatment patterns varied by data source, with agreement ranging from 76% to 82%. CONCLUSIONS: The validity and generalizability of these data demonstrate their potential for further health services research among younger insured women with breast cancer. Additionally, the process outlined may be useful for developing other datasets to study other cancers in the population younger than 65 years old.

Adult↗

PubMed2001

Informatics in managed care: HIM adds value to data.

The third installment of the Journal of AHIMA's special series on managed care focuses on informatics--methods that add value to data, turning it into useful information. How do informatics and managed care fit together and what is HIM's role in this picture? The HIM professional's knowledge is critical to the health team responsible for the interpretation and use of statically valid information. For example, HIM professionals are well positioned in their understanding of the construct and application of coding classification systems (ICD-9-CM, CPT, etc.), and groupers (DRGs, APCs, ETGs, etc.). Their unique training positions them to understand the associated rules, principles, guidelines, and nuances associated with correct coding and grouping. And when codes or groupers change, HIM professionals work closely with the health team to ensure parity, validity and reliability of the appropriate data or data sets. Managed care organizations use value-added data, as you will see in this article, to evaluate contract pricing, develop contracts, evaluate existing services or detail benefit plans, process and in some instances pay claims, and report results to a number of interested parties. The previous article in this series ("Can You Manage Managed Care?" July/August 2001) focused on effective management of data, including data acquisition. This article takes us to the next level, where informatics creates value-added information, and discusses some important uses of this information within managed care. These articles build on two of the functional areas that form the HIM process within managed care organizations. Author Scott Stratton studied under the creators of DRGs and was involved in the development of their nursing home counterpart, RUGs. He also has worked with the creators of ETGs. As a result, he can present the perspective and context within which these systems were created and intended. and how they form the foundation for informatics as a functional area within managed care.

Diagnosis-Related Groups↗