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PubMed2002

Economics of interstitial cystitis in clinical practice.

Urologists may be concerned that treatment of patients with interstitial cystitis (IC) is not economically feasible, and the time spent on these patients could be used for more profitable urologic therapy. However, care of IC patients can provide urologic practices with increased revenue opportunities through a wide range of procedures, including IC evaluation and management, treatment planning, and diagnostic, therapeutic, and even surgical techniques. Current Procedural Terminology (CPT) and evaluation and management (E&M) charge codes are provided for many types, levels, and complexities of IC procedures. Some of these treatments may use physician extenders who generate profits without additional overhead costs. Further, IC therapy may involve the use of many in-office services, such as urodynamics, biofeedback, and peripheral nerve stimulation that can be economically profitable. Rather than being an economic drain, patients with IC can enhance the profitability of a urologic practice while they receive much needed care.

Journal Article↗

PubMed1992

Will your Medicare claims stand up?

In the first two installments of our series, we gave you the details of reimbursement under the new Medicare fee schedule, and showed how to code evaluation-and-management services with the revised CPT system.* This issue, we'll tell what to expect from Medicare carriers as they teach and enforce the new payment rules.

Abstracting and Indexing↗

PubMed1991

Mitochondrial import and processing of rat liver carnitine palmitoyltransferase II defines the amino terminus of the mature protein. Possibility of differential modification of the rat and human isoforms.

[35S]Methionine-labeled porcine heart citrate synthase (used here as a positive control) and rat liver carnitine palmitoyltransferase II (CPT II) were generated by in vitro transcription and translation of their cDNA constructs in appropriate Bluescript plasmids. Each product was imported into rat liver mitochondria in an energy-dependent manner to yield an immunoprecipitable protein of smaller size that comigrated with the corresponding purified enzyme. The size shift occurring with citrate synthase was consistent with the removal of the postulated 27-amino acid leader peptide. To determine the amino terminus of mature CPT II, [35S]methionine- or [3H]leucine-labeled material (after import and processing) was subjected to Edman degradation, followed by counting of the radioactivity released on each cycle. The results established that the precursor targeting peptide was cleaved between leucine 25 and serine 26 in the previously deduced amino acid sequence. Taken in conjunction with the recent report of Finocchiaro et al. (Finocchiaro, G., Taroni, F., Rocchi, M., Martin, A. L., Colombo, I., Tarelli, G. T., and DiDonato, S. (1991) Proc. Natl. Acad. Sci. U.S.A. 88, 661-665), the present results establish three key points concerning the rat and human forms of CPT II. First, it appears that in both species the initial translation product contains 658 amino acids and, upon mitochondrial import, is reduced in length by 25 residues through cleavage at an identical site. Second, the difference in electrophoretic mobility between the two mature proteins (documented earlier) presumably reflects either anomalous behavior of one of them on polyacrylamide gels or differential covalent modification. Finally, the recent suggestion by Brady et al. (Brady, P. S., Liu, J. S., Park, E. A., Hanson, R. W., and Brady, L. J. (1991) FASEB J. 5, A817) that our CPT II cDNA construct is incomplete in the 5'-coding region is refuted.

Amino Acid Sequence↗

PubMed2005

Carnitine palmitoyltransferase II deficiency due to a novel gene variant in a patient with rhabdomyolysis and ARF.

Adult patients deficient in carnitine palmitoyltransferase II (CPT II) cannot generate sufficient amounts of energy, which results in rhabdomyolysis and acute renal failure (ARF). Its genetic basis has been recognized; but histopathologic changes, especially electron microscopic changes, have scarcely been described. The study subject is a patient with ARF caused by repetitive nontraumatic rhabdomyolysis. The acylcarnitine profile of serum and enzyme assay on skin fibroblasts confirmed the diagnosis of CPT II deficiency. Renal biopsy specimens were examined microscopically and immunohistochemically. The histological diagnosis was interstitial nephritis with acute tubular necrosis caused by rhabdomyolysis. Myoglobin in tubules was detected by means of immunohistochemistry and electron microscopy. The genetic structure of CPT II was analyzed in the patient and his family. Eight pairs of polymerase chain reaction (PCR) primers were designed to cover the coding region. Each PCR-amplified gene product was subjected to DNA sequencing, which unveiled heterozygosity at the CPT II locus consisting of a deletion of cytosine and thymine at codon 408, resulting in a stop signal at 420, as well as a mutation of arginine to cysteine at codon 631. The frame shift at 408 has never been described before. DNA sequencing of the family showed the deletion mutation from the mother and the point mutation from the father. We describe renopathological findings in a patient with CPT II deficiency associated with rhabdomyolysis, which suggested the pathological role of myoglobin casts in the development of tubular necrosis. Genetic analysis of the patient identified a novel variant of the CPT II gene.

Adult↗

PubMedDate not supplied

Pattern recognition in health insurance claims databases.

Information in claims databases resides in data patterns rather than in data elements. Finding this information requires new terminology, a willingness to pose questions of form rather than specific hypotheses, and a quality control system that elevates the correctness of data relations above the validity of single facts. The language of claims data is a newspeak of CPT (Current Procedural Terminology), HCPCS (Health Care Financing Agency Common Procedure Coding System), ICD (International Classification of Disease), and NDC (National Drug Codes) for pharmaceutical codes. The techniques of pattern discovery are really ways of asking the data for classes of relations, and they vary in their reliance on external information. Sometimes, the question is entirely constrained by preceding factors. Other times we may recast the natural history of disease into a claims context and ask the data to give us the shape of disease evolution. We can use highly automated systems to evaluate the relations between prespecified factors, or empirical techniques to search out common relations that we have not specified in advance. Using massive data sets requires that quality control corresponds to the nature of the high-level information that we derive from large databases.

Databases as Topic↗

PubMed1998

In their own words. Practice expenses and the resource-based relative value scale.

Dr. Opelka is a member of the College's CPT/RUC Committee, which makes recommendations about general surgery codes that should be added to, revised, or deleted from the CPT Manual. The committee also develops recommendations for the relative work values assigned to the general surgery services listed in the Medicare fee schedule. Because of his deep knowledge of the Medicare payment system, Dr. Opelka has frequently represented the College on panels convened by the federal government and in meetings with federal officials. In particular, he served recently on expert panels convened by the Health Care Financing Administration (HCFA) to develop direct cost data for the purpose of calculating resource-based practice expense relative values, which are scheduled to be incorporated into the Medicare fee schedule over a four-year period beginning in 1999. Dr. Opelka also participated in meetings that the General Accounting Office (GAO) requested with the College as part of its review of the methods being used by HCFA to generate the new practice expense values. Following are some of Dr. Opelka's thoughts about the federal government's efforts in this area.

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

PubMed1999

Treatment for early endometrial cancer. Cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness of treatment for early endometrial cancer. STUDY DESIGN: Cost-minimization type of cost-effectiveness analysis with payer costs based on CPT (physician's current procedural terminology) and DRG (disease related group) codes. The six principles of cost-effectiveness analysis were evaluated. We compared the standard treatment protocol of selected lymphadenectomy/selective teletherapy (lymphadenectomy and postoperative teletherapy administered for high-risk tumors) as performed by the majority of gynecologic oncologists vs. an alternate treatment protocol of lymphadenectomy/selective brachytherapy (lymphadenectomy for all tumors, brachytherapy for high-risk tumors and teletherapy reserved for nodal metastasis) as performed by 10-12% of gynecologic oncologists. RESULTS: In cost-minimization analysis, lymphadenectomy/selective brachytherapy was 12% less expensive than the standard treatment protocol of selective lymphadenectomy/teletherapy. CONCLUSION: Although only 10-12% of gynecologic oncologists perform lymphadenectomy on all patients, deliver brachytherapy for high-risk tumors and reserve teletherapy for lymph node metastasis, it is a cost-effective treatment strategy for early endometrial cancer.

Brachytherapy↗

PubMed2004

Relevance of different UGT1A1 polymorphisms in irinotecan-induced toxicity: a molecular and clinical study of 75 patients.

PURPOSE: We wanted to assess polymorphisms in the uridine diphosphoglucuronosyl transferase 1A1 (UGT 1A1) gene: the TATA box polymorphism and UGT 1A1 G71R and Y486D mutations in the coding sequence, the main mutations characterizing Gilbert's syndrome, as predictors of severe toxic event occurrence after irinotecan (CPT-11) administration. Therefore, we set up a rapid, sensitive, and reliable technique in routine practice to detect before CPT-11 treatment, the at-risk patients. EXPERIMENTAL DESIGN: Seventy-five patients with advanced colorectal cancer and treated with CPT-11 and 5-fluorouracil, entered the study. We used the Pyrosequencing technology a real-time sequencing method, to detect the UGT 1A1 TATA box polymorphisms and mutations in the coding regions. Patients were also assessed for both biochemical and clinical evaluation and tolerance to treatment. RESULTS: No G71R and Y486D mutations were found in our population. Frequencies for UGT 1A1 TATA box polymorphisms were 41, 47, and 9% for wild-type 6/6, heterozygous 6/7, and Gilbert's syndrome 7/7, respectively. Tolerance to treatment decreased with increased number of TA repeat with 71% of the patients in 7/7 group who experienced grade 3/4 toxicity. CONCLUSIONS: The method we set up is suitable for the detection of UGT 1A1 polymorphism in routine practice before irinotecan treatment. It could help to detect the patients homozygous or heterozygous for Gilbert's syndrome, at-risk of CPT 11-induced toxicity, and thus could help to individualize the dose to optimize efficacy and limit toxicity.

Adult↗

PubMed2005

Promoter methylation and differential expression of pi-class glutathione S-transferase in endometrial carcinoma.

Pi-class glutathione S-transferase (GSTP1), located on chromosome 11q13, codes for a phase II metabolic enzyme that detoxifies reactive electrophilic intermediates. The protein also interacts with steroid hormones in the human body. The role of GSTP1 in endometrial carcinoma has not been reported. In this study, we aimed at determining the expression of GSTP1 in relation to the epigenetic and genetic changes of the gene in endometrial carcinoma. The GSTP1 protein and mRNA expression was assessed by immunohistochemistry on tissue microarray and quantitative real-time reverse transcriptase-polymerase chain reaction, respectively. Its methylation status was studied by methylation-specific polymerase chain reaction and bisulfite sequencing. Possible mutations in coding region of GSTP1 were assessed by cDNA sequencing. Ninety-seven cases of endometrial carcinoma with available tissue blocks and clinical data were studied. Our results showed that 68.0% (66 of 97) of the cases showed reduced protein expression while 64% (16 of 25) showed reduced mRNA expression; 30.9% (30 of 97) of the cases demonstrated methylated alleles in at least one of the six methylation-specific polymerase chain reaction reactions. The methylation status significantly correlated with reduced protein expression (P = 0.008) and reduced mRNA expression (P = 0.003). Methylation at non-CpG sites including CpCpG trinucleotides and CpT dinucleotides were also observed. cDNA sequencing did not reveal genetic alterations in coding region of the gene. The extent of myometrial invasion was found to be significantly correlated with both the methylation status (P = 0.009) and the protein expression (P = 0.036) of the GSTP1 gene. We postulated that hypermethylation of the GSTP1 gene promoter region may act as a dynamic regulation mechanism contributing to reduced GSTP1 expression, which is associated with myometrial invasion potential of the endometrial carcinoma.

Adult↗

PubMed1991

Medicare reimbursement for geriatric assessment: report of the American Geriatrics Society Ad Hoc Committee on Geriatrics Assessment.

This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT-4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients. This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity--screening, intermediate, and comprehensive. It describes the major sites for conducting GA--hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.

Aged↗

PubMed1998

Diabetes prevalence and hospital and pharmacy use in the Veterans Health Administration (1994). Use of an ambulatory care pharmacy-derived database.

OBJECTIVE: To develop a diabetes registry from an outpatient pharmacy database to systematically analyze the prevalence of diabetes, patterns of glycemic medication and glucose monitoring, pharmacy costs, and hospital use related to diabetes care in the Veterans Health Administration (VHA) in fiscal year (FY) 1994. RESEARCH DESIGN AND METHODS: Veterans with diabetes were identified using a software program that extracted the social security number (SSN) of patients receiving insulin, sulfonylurea agents, or glucose-monitoring supplies. The cumulative FY94 cost for a drug was calculated by multiplying the units dispensed times the unit cost for each fill, using the actual drug cost that was in effect at the time of dispensing. Admission data were obtained by crossmatching the SSN registry with the VHA Austin Mainframe Patient Treatment Files to retrieve associated diagnosis-related groups (DRG), Physicians' Current Procedural Terminology (CPT), and International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes. RESULTS: From among 1,180,260 unique patients, 139,646 veterans with diabetes receiving insulin, oral agents, or glucose-monitoring strips were identified, accounting for a prevalence of 11.83% from 62 Veterans Administration medical centers. There were 63,078 individuals (52%) who received oral agents, of whom 26.3% also received blood glucose-monitoring supplies; 46,664 individuals (39%) received insulin, of whom 53.2% received blood glucose-monitoring supplies; and 9,440 individuals (8%) received both oral agents and insulin during FY94, with 64.4% receiving blood glucose-monitoring supplies. Only 1,482 (1.2%) individuals received monitoring supplies alone, and 129 patients (0.1%) were provided with an insulin pump. Using an adjusted data set, 12% of veterans accounted for 24% of all outpatient pharmacy costs, with an average expenditure of $622 for veterans with diabetes compared with $276 for veterans without diabetes. There was $454 (73%) for non-diabetes-specific prescriptions and $168 (27%) for prescriptions related to glycemic control. Of pharmacy expenditures for glycemic control, $101 (60.1%) was attributed to insulin, oral agents, and supplies, while $67 (39.9%) was attributable to glucose monitoring. Veterans with diabetes were admitted 1.6 times as frequently as veterans without diabetes. CONCLUSIONS: This study demonstrates the feasibility of using a pharmacy-based electronic diabetes database in a payor system that can track both claims and individual classes of medication based on a unique identifier number. While the prevalence of diabetes in the VHA is high relative to other health care systems and the general population, patterns of medication usage, pharmacy costs, and relative admission frequency are comparable to results from the private sector.

Ambulatory Care↗

PubMed2000

Clarifying selected CPT modifiers.

This discussion includes only 20 percent of the modifiers available for physician reporting, but could account for 80 percent of modifiers assigned for physician services. Modifier -91 was the only new modifier introduced in CPT 2000 and it is used to report a repeat clinical diagnostic laboratory test. It is not to be used when confirming initial results or for any other reason other than a clinical need to repeat the test for the same patient on the same day. Success with CPT modifier reporting requires a thorough review of CPT guidelines and some detective work for identifying health plan requirements for modified codes.

Abstracting and Indexing↗

PubMed2005

Representation of ophthalmology concepts by electronic systems: adequacy of controlled medical terminologies.

OBJECTIVE: To assess the adequacy of 5 controlled medical terminologies (International Classification of Diseases 9, Clinical Modification [ICD9-CM]; Current Procedural Terminology 4 [CPT-4]; Systematized Nomenclature of Medicine, Clinical Terms [SNOMED-CT]; Logical Identifiers, Names, and Codes [LOINC]; Medical Entities Dictionary [MED]) for representing concepts in ophthalmology. DESIGN: Noncomparative case series. PARTICIPANTS: Twenty complete ophthalmology case presentations were sequentially selected from a publicly available ophthalmology journal. METHODS: Each of the 20 cases was parsed into discrete concepts, and each concept was classified along 2 axes: (1) diagnosis, finding, or procedure and (2) ophthalmic or medical concept. Electronic or paper browsers were used to assign a code for every concept in each of the 5 terminologies. Adequacy of assignment for each concept was scored on a 3-point scale. Findings from all 20 case presentations were combined and compared based on a coverage score, which was the average score for all concepts in that terminology. MAIN OUTCOME MEASURES: Adequacy of assignment for concepts in each terminology, based on a 3-point Likert scale (0, no match; 1, partial match; 2, complete match). RESULTS: Cases were parsed into 1603 concepts. SNOMED-CT had the highest mean overall coverage score (1.625+/-0.667), followed by MED (0.974+/-0.764), LOINC (0.781+/-0.929), ICD9-CM (0.280+/-0.619), and CPT-4 (0.082+/-0.337). SNOMED-CT also had higher coverage scores than any of the other terminologies for concepts in the diagnosis, finding, and procedure categories. Average coverage scores for ophthalmic concepts were lower than those for medical concepts. CONCLUSIONS: Controlled terminologies are required for electronic representation of ophthalmology data. SNOMED-CT had significantly higher content coverage than any other terminology in this study.

Humans↗

PubMed2001

Lightening the burden of the heavy regulatory hand an incentive for outpatient computer patient record.

However many benefits may be achieved for the organization, it is difficult to introduce a computer patient record (CPR) into an outpatient setting until the clinical practitioners themselves see direct benefit from the time invested. The ever increasing burden of regulation on health care in the outpatient setting includes (but is not limited to) guidelines for evaluation and management (E&M) coding, Local Medical Review Policy (LMRP) rules for diagnostic justification of tests and procedures and associated requirements for Advance Beneficiary Notification (ABN), and the rules for teaching physicians in academic settings. Achieving compliance with just the LMRP rules requires immediate access to an eight-inch-thick stack of manuals (ICD9, CPT, HCPCS, and LMRP), 4 inches of which is subject to update on a monthly basis. Accurate E&M coding is about as complicated as using the long form to do one s tax return. Without tools that can be provided by the CPR, these requirements add significant time to the patient encounter and significant risk of non-compliance and fines. We report our strategy for deploying the CPR as a strategy to keep clinicians from being overwhelmed by the rules, thereby allowing them to focus on healthcare. In the context of the CPR, and against all odds otherwise, the impact of the regulations can sometimes have beneficial and educational impacts on clinical care.

Attitude of Health Personnel↗

PubMed1983

Biosynthesis of carnitine octanoyltransferase and carnitine palmitoyltransferase.

Male Wistar rats were fed a diet with or without di(2-ethylhexyl)phthalate (DEHP) for 2 weeks. Carnitine octanoyltransferase (COT) in the liver was increased 23.5-fold in rats given DEHP. It was found by in vivo experiments using L-[4,5-3H]leucine and the immunoprecipitation technique that the rate of synthesis of COT was 14.1-fold higher and that of its degradation was 1.5-fold lower in the DEHP group. COT was translated much more effectively in free polysomes than in membrane-bound polysomes. The molecular size of the in vitro product was the same as that of the mature enzyme. The translation activity of mRNA coding for COT measured with total hepatic RNA was 16.6-fold higher in the DEHP group. Carnitine palmitoyltransferase (CPT) was increased 5.9-fold after administration of DEHP. The rate of synthesis of CPT measured in the in vivo experiment was 5.0-fold higher in the DEHP group. The rate of its degradation was the same in the two groups. CPT was also translated much more effectively in free polysomes. The size of the preenzyme was larger than that of the subunit of the mature enzyme by about 2,400 daltons. In contrast to COT, the increase in the translation activity of mRNA for CPT by administration of DEHP was markedly higher than the increase in the rate of its synthesis measured in the in vivo experiment.

Acyltransferases↗

PubMed1995

Resource-Based Relative Value Scales: impacts and recommendations relative to chiropractic practice.

PURPOSE: The American health care financing and delivery system is changing at a rapid pace. As part of recent reform of payment systems for physician services, Medicare has adopted a resource-based relative value scale (RBRVS) that is becoming a national standard. Research has now documented characteristics of physicians' work and the overhead for providing specific health services for most medical specialties and disciplines. This information is being used to develop service descriptions (billing codes) and reimbursement levels. No such data exist relative to chiropractic, which may hinder chiropractic's efforts to be included in evolving reimbursement schemes. RBRVS and its relevance to chiropractic is reviewed, information on work levels and practice costs is discussed, chiropractic practice is reviewed and a research and policy agenda for documenting chiropractic work, overhead and service descriptions is provided. METHODOLOGY: A manual systemic review of available recent and relevant medical and chiropractic literature was undertaken to characterize how the RBRVS system for reimbursement of physician services was developed and implemented. Payer and trade association literature was used to determine what established work value and practice costs for DCs there are. Published payment scales from governmental commissions were also obtained. CONCLUSIONS: Resources are urgently needed to survey levels of work by chiropractors in providing their various health services. The methodology should be the one used by the Health Care Financing Administration to assess other specialties. A range of generic manipulation codes should be developed and tested in a similar fashion for submission for inclusion in Physician's Current Procedural Terminology (CPT). A seed range of descriptions is presented. A systematic collection of practice overhead costs and malpractice risk should be undertaken and documented using standardized methodology.

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

PubMed2003

Glucuronidation of 7-ethyl-10-hydroxycamptothecin (SN-38), an active metabolite of irinotecan (CPT-11), by human UGT1A1 variants, G71R, P229Q, and Y486D.

7-Ethyl-10-hydroxycamptothecin (SN-38), an active metabolite of antitumor agent irinotecan (CPT-11), is conjugated and detoxified to SN-38-glucuronide by UDP-glucuronosyltransferase (UGT) 1A1. Genetic polymorphisms in UGT1A1 are thought to contribute to severe diarrhea and/or leukopenia caused by CPT-11. In this regard, it has been reported that polymorphisms in the promoter region could affect the CPT-11 pharmacokinetics and interindividual variation of toxicity. However, little information is available on the influence of UGT1A1 polymorphisms in the coding region on the SN-38 glucuronidation activity. In the present study, wild-type (WT) and three variant (G71R, P229Q, and Y486D) cDNAs of human UGT1A1s were transiently expressed in COS-1 cells, and the kinetic parameters of these UGT1A1s were determined for SN-38 glucuronidation. A partially reduced UGT1A1 protein expression was observed in COS-1 cells for G71R and Y486D. WT UGT1A1 catalyzed SN-38 glucuronidation with an apparent K(m) value of 11.5 microM, whereas those of G71R, P229Q, and Y486D were 14.0, 18.0, and 63.5 microM, respectively. The SN-38 glucuronidation efficiency ratio (V(max)/K(m)) normalized for the level of expression was 1.4, 0.66 (47% of WT), 0.73 (52%), and 0.07 (5%) microl/min/mg of protein for WT, G71R, P229Q, and Y486D, respectively. Thus, the SN-38 glucuronidation activity of Y486D was drastically reduced, whereas the reduction in the G71R and P229Q activities was fractional. The decreased SN-38 glucuronidation efficiency ratio of G71R and P229Q could be critical in combination with other polymorphisms in the UGT1A1 gene.

Amino Acid Substitution↗

PubMed2006

Physician documentation essential for accurate coding and billing of excision of skin lesions.

Clear and precise documentation is essential to accurately code and bill for excision of benign or malignant skin lesions. Detailed documentation is crucial for capturing the full allowable reimbursement when the procedure involves more than a simple closure. For each lesion, only one type of removal may be reported, whether it is destruction, debridement, paring, curettement, shaving or excision. If an initial attempt to remove a lesion by a less invasive procedure is immediately followed by a more invasive lesion removal, only the more complex, definitive procedure may be billed. According to the Current Procedure Terminology manual (CPT), an excision of a skin lesion is defined as "full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed." Changes in recent years now allow code selection based on the greatest clinical diameter of the lesion plus the narrowest margin required for adequately excising the lesion, "based on the physician's judgment." According to CPT, the "measurement of lesion plus margin is made prior to excision".

Current Procedural Terminology↗