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PubMed2002

Relational data model for the American College of Radiology Appropriateness Criteria.

This article describes a data model for encoding the American College of Radiology Appropriateness Criteria (ACRAC) for selection of diagnostic imaging procedures. These guidelines are recognized widely as an authoritative repository of "best evidence" concerning appropriate radiology tests for a large number of clinical conditions. In its current text document format, the ACRAC is of limited utility for electronic use. The data model the authors propose completely encodes all attributes and domains of the published guidelines and is suitable for translation into any industry standard relational database system. Additionally, the authors have added mappings onto commonly used procedure (CPT) and clinical problem (ICD) coding systems. When populated with the current ACRAC content, such a database could serve as the "master" repository of the guidelines with changes and additions made via an interface built with standard database application development tools. The database also could be made available for incorporation into existing information systems used for order entry, decision support, compliance tracking, and health services research at regional and national levels.

Databases, Factual↗

PubMedDate not supplied

Nutrition counseling in the physician's office: how do I bill for advising my patient?

In addition to diagnosing and treating illnesses, physicians often provide nutrition counseling services. Billing and obtaining appropriate reimbursement for these services present a unique challenge. This article utilizes 4 hypothetical scenarios as a basis for examining common categories of service that involve nutrition counseling. These categories are: routine physicals that include nutrition counseling, nutrition counseling alone, nutrition counseling as a small part of a problem-oriented "evaluation and management" (E/M) service, and nutrition counseling as the bulk of a problem-oriented E/M service. The basics of procedure (CPT) and diagnosis (ICD-9) coding are described, and specific billing instructions for each scenario are provided. Although this article provides an introduction to the topic of billing, healthcare providers and their office staff should inform themselves on general coding and billing practices, as well as local payors' guidelines.

Adult↗

PubMed2001

Recurrence and malignancy rates in a benign colorectal neoplasm patient cohort: results of a 5-year analysis in a managed care environment.

OBJECTIVE: To estimate the apparent recurrence rates of benign neoplasms and the development of malignant colorectal neoplasms over a 5-yr period in a high risk managed care population. METHODS: Using the CPT and ICD-9 CM codes, a cohort of subjects with benign neoplasms were identified with a colonoscopy in 1992 from a longitudinal claims database (MarketScan). Three groups of subjects (benign neoplasms with polypectomy, benign neoplasms without polypectomy, and no neoplasms) were evaluated. Five-year recurrence rates of benign or new malignant colorectal neoplasms were determined for the baseline benign neoplasms with polypectomy and no neoplasm groups. For the benign neoplasm without polypectomy, only rates for malignancy were evaluated. RESULTS: Of 16,293 subjects at baseline, 39.50% were diagnosed with benign and 5.50% with malignant neoplasms. The 5-yr cumulative incidence of benign neoplasms in subjects without an index neoplasm (n = 8,967) was 7.92% compared to the recurrence of 40.93% in subjects with a benign neoplasm and polypectomy (n = 4,046) at baseline (p < 0.001). The 5-yr cumulative incidence rates of malignant colorectal neoplasms in the no neoplasm (n = 8,967) and benign neoplasm groups (n = 6,438) were 1.81% and 2.55%, respectively (p < 0.005). A lower 5-yr malignancy rate was observed in benign neoplasm group with polypectomy (2.17%) compared to the benign neoplasm group without polypectomy (3.18%) (p < 0.05). CONCLUSION: The high recurrence rate of benign colorectal neoplasms and a higher incidence of colorectal cancer in subjects at high risk (history of benign colorectal neoplasm) highlight a healthcare opportunity for surveillance and/or interventions to reduce the morbidity associated with colorectal neoplasms.

Adult↗

PubMed2006

Treatment patterns for women with new episodes of uterine myomas in an insured population in the US.

INTRODUCTION: Uterine myomas are the most common benign tumors in reproductive-aged women and a leading reason for gynecologist visits and hysterectomies in the United States. This study examines the treatment patterns of insured women with new episodes of uterine myomas. MATERIALS AND METHODS: We used administrative claims from a proprietary research database to evaluate services (inpatient, outpatient, and prescription claims) incurred from January 1, 2001 to December 31, 2003. We identified women with CPT or ICD-9-CM codes suggestive of myoma and described treatment patterns for all women with a new episode of myoma and those with abnormal bleeding. RESULTS: The primary study group included 35 329 women with new episodes of care and at least three months of data before and after their index date for myoma. Most women (82.9%) had no code for diagnostic testing in the three months before or after the first myoma marker. Of 14 434 women with one year of follow-up, 26.1% had surgery and 24.7% were treated pharmacologically (oral contraceptives, progestins, or gonadotropin-releasing hormone agonists). Over half (55.1%) of women were untreated, including 45% of those with an ICD-9 code that indicated abnormal bleeding. CONCLUSIONS: Women with new myoma episodes rarely had codes for confirmatory diagnostic tests. Many women with myomas go untreated for at least a year. This is true even for those with evidence of abnormal bleeding. Myoma care may be improved through the introduction of new, safe, and effective therapies.

Adolescent↗

PubMed2005

Automated mapping of local radiology terms to LOINC.

We developed an automated tool, called the Intelligent Mapper (IM), to improve the efficiency and consistency of mapping local terms to LOINC. We evaluated IM's performance in mapping diagnostic radiology report terms from two hospitals to LOINC by comparing IM's term rankings to a manually established gold standard. Using a CPT-based restriction, for terms with a LOINC code match, IM ranked the correct LOINC code first in 90% of our development set terms, and in 87% of our test set terms. The CPT-based restriction significantly improved IM's ability to identify correct LOINC codes. We have made IM freely available, with the aim of reducing the effort required to integrate disparate systems and helping move us towards the goal of interoperable health information exchange.

Artificial Intelligence↗

PubMed2003

Molecular cloning and characterization of the guinea pig cholinephosphotransferase gene.

Cholinephosphotransferase (CPT), the terminal enzyme in the de novo synthesis of phosphatidylcholine (PC), has an important role in regulating the acyl group of PC in mammalian cells. A 593bp cDNA coding for the 3(')-end of the CPT gene has been cloned from guinea pig liver using degenerative oligos based on the human CPT gene. It has 85% amino acid homology with the human CPT enzyme and amino acid variations were found to cluster at few points. Restriction enzyme polymorphisms were found particularly with respect to BamHI and NcoI. Hydrophobic and helix plot analysis of the sequence shows a similar pattern to human counterpart except for amino acid residues 142-179 and 173-179. PCR analysis suggested that a predominant pseudogene may be present in guinea pig and also the intronic sequences were much shorter when compared to the human CPT gene. We are the first to report on the C-terminal 195 amino acid residues of the CPT gene from any animal species alike in many aspects of cellular metabolism. The probable differences in genomic organization and its expression in different cancer cells have been discussed here having CPT as an important target for cancer drug development.

Amino Acid Sequence↗

PubMed2003

Management of osteoporosis in women aged 50 and older with osteoporosis-related fractures in a managed care population.

This study describes the pattern of evaluation and management of osteoporosis in women aged 50 and older following an osteoporosis-related fracture, conducted as a retrospective cohort study using the administrative claims database of a managed care organization. Subjects were women, aged 50 years and older, with at least one osteoporosis-related fracture in the years 1996-1998 who were continuously enrolled in the system's health plan for at least 6 months prior to and post-fracture. Bone mineral density (BMD) testing, diagnosis of osteoporosis, and treatment with any Food and Drug Administration-approved medication for osteoporosis were identified using CPT, ICD-9, and National Drug Codes for the 6-month post-fracture period. There were 658 women with an osteoporosis-related fracture: 189 (29%) hip fractures, 226 (34%) wrist fractures, 127 (19%) vertebral fractures, and 116 (18%) rib fractures. In the post-fracture period, 46 (7%) underwent BMD testing, 153 (23%) had a diagnosis of osteoporosis, and 220 (31%) were treated with a medication approved for the prevention or treatment of osteoporosis. Of the 220 women with medication claims, 124 (56%) were for estrogen, and 96 (44%) were for other antiresorptive agents. Of the 507 women who did not have medication claims during the 6 months prior to the fracture, only 17% had new fills after the fracture. Management of osteoporosis in women aged 50 and older with fractures was inadequate, despite the high risk of subsequent fractures and recommendations that osteoporosis be the presumptive diagnosis. Significant opportunity exists for improvement in assuring post-fracture followup care.

Aged↗

PubMed1993

Expression of precursor and mature carnitine palmitoyltransferase II in Escherichia coli and in vitro: differential behaviour of rat and human isoforms.

cDNAs corresponding to the precursor and mature forms of rat carnitine palmitoyltransferase II (CPT II) were found to be readily expressed in Escherichia coli. In both cases, catalytically active immunoreactive protein was produced and became largely membrane-associated. The precursor form of the enzyme was not proteolytically processed. Removal of 126 bp from the 5' end of the cDNA coding region allowed expression of a truncated CPT II (lacking the N-terminal 17 residues of the mature protein), but this product was inactive. cDNAs encoding the precursor and mature forms of human CPT II resisted direct expression in E. coli. However, the impediment was overcome when the latter cDNA was ligated in-frame 3' to sequence encoding a glutathione S-transferase. This construct yielded abundant quantities of the corresponding fusion protein, a portion of which was soluble and catalytically active. In vitro transcription and translation of the various cDNAs established that the lower mobility on SDS/PAGE of rat CPT II compared with its human counterpart (despite their identical numbers of amino acids) is an intrinsic property of the primary sequences of the proteins themselves. Also, the human cDNA was found to contain an artifactual termination signal for T3 RNA polymerase that could be bypassed by the T7 polymerase. Thus rat CPT II can be expressed in active form in E. coli with characteristics similar to those of the enzyme in mitochondria, opening the way to future location of active sites within the molecule. An alternative expression system will be needed for similar studies on human CPT II.

Animals↗

PubMed1993

Current procedural terminology coding of nuclear medicine procedures.

The future of nuclear medicine is dependent on payment for new procedures. Today, the basis of payment by the federal government is a relative value unit (RVU) system; the RVUS employed in this system are for medical services and procedures listed and described in Physicians' Current Procedural Terminology, fourth edition. Current procedural terminology (CPT) is maintained by the AMA; annual revisions include adding new codes or revised or deleted old codes. This process involves all national medical specialty societies. Starting in 1992 a new process, the Relative Updating Committee, which was initiated by the AMA, organized medicine to formalize a method for recommending relative values for physician procedures and services. In this rapidly changing scenario, all nuclear medicine procedure codes are under review by the coding and nomenclature committees of the medical societies interested in imaging. Significant CPT changes and additions were made in the cardiovascular nuclear medicine codes in 1992, reflecting the current imaging protocols and pharmacological agents for performing cardiac stress testing and new codes that recognize combinations of ventricular function measurements in patients undergoing myocardial perfusion imaging with technetium-99m agents.

American Medical Association↗

PubMed2000

Clinical vocabularies and terminologies: impact on the future of health information management.

As standardized clinical vocabularies and terminologies are being developed, Health Information Management (HIM) practitioners must increase their knowledge of nomenclature and coding systems beyond the traditional ICD-9-CM and CPT. The limited scope of these classifications prevents them from serving as the standard vocabulary for the computer-based patient record. The American Health Information Management Association (AHIMA) Coding Futures Task Force provided insights into the knowledge and skills that HIM professionals will need as clinical vocabularies and terminologies become more integrated into health care systems. Certain characteristics are important in a clinical vocabulary and several clinical vocabularies are in use today.

Abstracting and Indexing↗

PubMed2006

Population-based trends in volumes and rates of ambulatory lumbar spine surgery.

STUDY DESIGN: Sequential cross-sectional study. OBJECTIVES: To quantify patterns of outpatient lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Outpatient lumbar spine surgery patterns are undocumented. METHODS: We used CPT-4 and ICD-9-CM diagnosis/procedure codes to identify lumbar spine operations in 20+ year olds. We combined sample volume estimates from the National Hospital Discharge Survey (NHDS), the National Survey of Ambulatory Surgery (NSAS), and the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) with complete case counts from HCUP's State Inpatient Databases (SIDs) and State Ambulatory Surgery Databases (SASDs) for four geographically diverse states. We excluded pregnant patients and those with vertebral fractures, cancer, trauma, or infection. We calculated age- and sex-adjusted rates. RESULTS: Ambulatory cases comprised 4% to 13% of procedures performed from 1994 to 1996 (NHDS/NSAS data), versus 9% to 17% for 1997 to 2000 (SID/SASD data). Discectomies comprised 70% to 90% of outpatient cases. Conversely, proportions of discectomies performed on outpatients rose from 4% in 1994 to 26% in 2000. Outpatient fusions and laminectomies were uncommon. NIS data indicate that nationwide inpatient surgery rates were stable (159 cases/100,000 in 1994 vs. 162/100,000 in 2000). However, combined data from all sources suggest that inpatient and outpatient rates rose from 164 cases/100,000 in 1994 to 201/100,000 in 2000. CONCLUSIONS: While inpatient lumbar surgery rates remained relatively stable for 1994 to 2000, outpatient surgery increased over time.

Adult↗

PubMed2002

Trends in the utilization of MR angiography and body MR imaging in the US Medicare population: 1993-1998.

PURPOSE: To determine the trends in utilization of non-neurologic (ie, body) magnetic resonance (MR) imaging and of MR angiographic examinations performed from 1993 to 1998, the trends in non-radiologist participation in MR imaging, and the relative reimbursements for these examinations compared with those for all other noninvasive imaging studies performed in 1998. MATERIALS AND METHODS: By using the 1993, 1996, and 1998 nationwide Medicare Part B databases, utilization rates per 100,000 Medicare beneficiaries and physician reimbursements were determined for seven MR angiography and 14 body MR imaging CPT-4 (Current Procedural Terminology, version 4) codes. Medicare specialty codes were used to categorize physicians as radiologists or non-radiologists. RESULTS: The utilization rate per 100,000 Medicare beneficiaries for all 21 MR angiography and body MR imaging codes increased from 649 in 1993 to 1,253 in 1996 and to 1,876 in 1998--a 189% increase. These rates represented 0.55% of the total noninvasive imaging volume in 1998 and 2.8% of physician reimbursements. Musculoskeletal MR imaging utilization increased 142% from 1993 to 1998 compared with a 58% increase in the utilization of other body MR imaging studies. Non-radiologist participation in musculoskeletal MR imaging increased from 2.9% in 1993 to 3.6% in 1996 and to 5.6% in 1998. CONCLUSION: MR angiography and body MR imaging utilization rates increased substantially from 1993 to 1998. However, these studies still account for a minor fraction of all noninvasive imaging examinations performed and fees reimbursed. MR angiography and musculoskeletal MR imaging utilization has increased rapidly. Non-radiologist participation in musculoskeletal MR imaging is increasing.

Aged↗

PubMed1998

Identification of four novel mutations in patients with carnitine palmitoyltransferase II (CPT II) deficiency.

Carnitine palmitoyltransferase II (CPT II) deficiency, an autosomal recessive disorder of fatty-acid oxidation, presents as three distinct phenotypes (neonatal, infantile, and adult onset). In order to investigate the molecular basis of these three phenotypes, six patients with CPT II deficiency have been studied. All six unrelated patients in this study experienced the clinical symptoms of CPT II deficiency. Three patients had the neonatal form, one had the milder infantile form, and the remaining two had the adult-onset form with "muscular" symptoms only. Their diagnoses were based upon in vitro analysis of the mitochondrial beta-oxidation pathway in fibroblasts and standard enzyme assays. We devised a method to screen the entire coding sequence and flanking splice junction of the CPT II gene. A total of six different mutations have been identified, including four novel mutations. Among them, the previously reported common mutation, S113L, was only found in 3 of 12 variant alleles. Three of the six mutations have been identified in a few unrelated patients, while the remaining three have been found in single families. This study, as well as those by others, indicates genetic heterogeneity in this disease. In addition to tabulating the mutations, the correlation of mutant genotype to clinical phenotype is briefly discussed.

Adult↗

PubMed1992

Isolation and characterization of the promoter for the gene coding for the 68 kDa carnitine palmitoyltransferase from the rat.

Carnitine palmitoyltransferase (CPT) regulates the flux of long-chain fatty acids into the mitochondria for subsequent beta-oxidation. A 485 bp segment of the promoter for the gene encoding the 68 kDa CPT was isolated from a rat lambda DASH genomic library using the polymerase chain reaction. The promoter contained a consensus binding sequence for CREB (cyclic AMP response element binding protein) at -153 to -166, and for C/EBP alpha (CCAAT/enhancer binding protein) at -115 to -128. DNAase I footprinting using proteins isolated from rat liver nuclei indicated the presence of several regions of nuclear protein binding, most notably at -95 to -130, at -273 to -295, and at a wide region encompassing -395 to -465. DNAase I footprinting studies with purified CREB and C/EBP alpha confirmed that protein binding to DNA occurred at the sites predicted by the consensus sequences. The segment containing 481 bp of 5' flanking sequence plus 181 bp of untranslated mRNA was ligated to the structural gene for chloramphenicol acetyltransferase (CAT). When this plasmid was transfected into Hep G2 cells, CAT activity was stimulated 7-fold by addition of 1 mM-8-bromo-cyclic AMP (8-Br-cAMP) or co-transfection of the expression vector coding for the catalytic subunit of protein kinase A (PKA). The ability of several known second messengers and transcription factors to stimulate transcription of 68 kDa CPT promoter-CAT reporter was tested in co-transfection experiments. 68 kDa CPT promoter-CAT reporter transcription activity was stimulated 7-fold by addition of 8-Br-cAMP, and this induction was depressed 50% by the addition of phorbol esters. When the 68 kDa CPT promoter-CAT reporter was co-transfected with an expression vector for CREB or C/EBP alpha, transcription was increased 3- and 10-fold respectively. 8-Br-cAMP caused an additional 8-fold induction in the presence of each factor to yield 25- and 80-fold induction respectively. Co-transfection of the expression vector for c-jun also increased the CAT activity driven by the 68 kDa CPT promoter, while co-transfection with the expression vector for c-fos had no effect. When expression vectors for both c-jun and c-fos were co-transfected with the 68 kDa CPT promoter, c-fos depressed the induction seen with c-jun alone.

Animals↗

PubMed1998

Genomic DNA sequence, promoter expression, and chromosomal mapping of rat muscle carnitine palmitoyltransferase I.

Carnitine palmitoyltransferase I (CPT-I) is a key enzyme involved in the regulation of fatty acid oxidation. CPT-IA and CPT-IB are isoforms of carnitine palmitoyltransferase I, of which CPT-IA is expressed in liver, kidney, fibroblasts, and heart and CPT-IB is expressed in skeletal muscle, heart, brown and white adipocytes, and testes. Although the genomic DNA sequence of human CPT-IB is available, the transcription start site and upstream regulatory sequences are not known. For rat CPT-IB, only the cDNA sequence has been published. We have cloned the entire rat CPT-IB gene from a Lambda fix II rat kidney genomic library. The genomic structure contains 19 exons, with the transcription start site for CPT-IB located in a short first exon, which is a 13-bp extension to the previously published cDNA 5' sequence. The coding sequence is identical with the rat muscle cDNA. The rat CPT-IB gene contains 18 introns and 19 exons, the latter 18 exons showing 85% homology to the human CPT-IB cDNA. CPT-IB maps to rat chromosome 7 at band q34. A putative promoter region was identified to within 391 bp of the transcription start site. The muscle specificity of the 5' flanking region was verified by comparison of luciferase expression to that of beta-galactosidase in cardiac myocytes and in HepG2 cells.

Animals↗

PubMed1999

The impact of national correct coding policy on interventional pain management.

Health Care Financing Administration ("HCFA") created the National Correct Coding Council ("NCCC") to help ensure that providers across various jurisdictions received like payment for the same services and use the same codes and provide similar documentation for services performed. As a direct out growth of NCCC's work, HCFA established the National Correct Coding Policy in 1996 and eventually implemented the Medicare "Correct Coding Initiative" to identify and isolate inappropriate coding, unbundling, and other irregularities in coding. To appropriately implement National Correct Coding Policy in interventional pain management an interventional pain management specialist and their staff must be familiar with correct coding policies as well as understand the physicians current procedural terminology (CPT, medical surgical practice and packages, modifiers, separate procedures, comprehensive and component services, incorrect coding/unbundling and various specific issues relevant to practice of interventional pain management) Comprehensive codes include certain defined services that are separately identifiable by other codes known as component codes. Because component codes are captured by comprehensive codes they man not be listed separately when the complete procedure is done. For example, in interventional pain management, 62279, which is continuous lumbar epidural, is considered a comprehensive code. Various component codes include 62270, 62272 - 62274, 62276 - 62278, 62288 and 62289, among others. This review describes National Correct Coding Policy, correct procedural terminology, medical and surgical practice and packages, evaluation and management services along with description of most codes used in interventional pain management with correcting coding edits for comprehensive codes and for mutually exclusive codes.

Journal Article↗

PubMed1996

The effect of surgical treatment following peritoneal sepsis on hepatic gene expression.

Peritoneal sepsis results in downregulation of the gene that codes for the hepatic mitochondrial enzyme carnitine palmitoyltransferase (CPT). The inhibition of hepatic CPT transcription by sepsis is thought to be mediated, in part, by increased expression of the leucine-zipper DNA transcription factor c-fos. In a cecal ligation and puncture (CLP) model, we examined the temporal effect of surgical treatment (cecal excision) on sepsis-induced inhibition of CPT gene expression. We investigated the hypothesis that Fos protein level will inversely correlate with the regulation of CPT gene expression. Specifically, we studied hepatic Fos nucleoprotein accumulation and CPT gene expression as measured by total mitochondrial CPT activity, CPT protein, and CPT mRNA. We investigated the following groups: (i) CLP followed by cecal excision 6, 12, or 24 hr following initial insult, (ii) concurrent CLP control group, and (iii) concurrent sham CLP reference group. When measured 48 hr following initial surgical insult, we conclude that: (i) in the absence of surgical treatment, peritoneal contamination results in a decrease in hepatic CPT gene expression and an increase in Fos nucleoprotein accumulation; (ii) surgical treatment at 6 or 12 hr following initial insult prevents the downregulation in hepatic CPT gene expression and does not result in Fos nucleoprotein accumulation; and (iii) surgical treatment at 24 hr following insult did not prevent the downregulation of hepatic CPT gene expression and results in an increase in hepatic Fos nucleoprotein accumulation. These data are consistent with the hypothesis that sepsis-induced regulation of hepatic c-fos gene expression, in part, is responsible for the downregulation of CPT gene expression.

Animals↗

PubMed1999

Understanding the Bone Mass Measurement Act.

The Bone Mass Measurement Act (BMMA) set forth regulations to provide for uniform coverage under Medicare Part B for bone mass measurements for services provided on or after July 1, 1998. The BMMA authorizes Medicare coverage of "medically necessary approved measurements" performed for a "qualified individual" who falls into at least one of five diagnostic categories: an estrogen-deficient woman at clinical risk for osteoporosis; an individual with vertebral abnormalities; an individual receiving long-term glucocorticoid (steroid) therapy; an individual with primary hyperparathyroidism; and an individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy. Proper communication is essential for reimbursement. The tools for communication include Physician's Current Procedural Terminology (CPT), HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS), the Medicare carrier's local Medical Review Policy (LMRP), and the International Classification of Diseases, ninth revision (ICD-9). This article reviews the new regulations and the tools for communication.

Absorptiometry, Photon↗