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PubMed1997

Comparison of nursing interventions classification and current procedural terminology codes for categorizing nursing activities.

PURPOSE: To compare the frequency with which nursing activity terms could be categorized using Nursing Interventions Classification (NIC) and Current Procedural Terminology (CPT) codes. DESIGN: Descriptive. The sample was 201 patients with AIDS hospitalized 1989-1992 for pneumocystis carinii pneumonia in three US medical centers. METHODS: Nursing activity terms (n = 21,366) were collected from patient interviews, nurse interviews, intershift reports, and patient records, then were categorized using NIC and CPT codes. RESULTS: Nursing activity terms were categorized into 80 NIC interventions across 22 classes and into 15 CPT codes. All terms in the data set were classifiable using the NIC system and the majority (60%) of the terms were classified into 14 NIC intervention categories; 6% of the terms were classifiable by CPT codes. The most frequently used CPT code was "pulse oximetry." Significantly (p < .0001) greater numbers of nursing activity terms could be categorized in the NIC system compared to the CPT system. CONCLUSIONS: Findings provide evidence that NIC is superior to CPT for categorizing nursing activities in this study's population. The findings support the importance of discipline-specific classifications for categorization of health care interventions. Nursing-specific intervention classification systems such as NIC, the Omaha System, and the Home Health Care Classification are essential to defining the contribution of nursing to both quality and cost outcomes.

Adult↗

PubMedDate not supplied

Here we go again!

New CPT procedure codes are added annually (quarterly for Category II and Category III codes), definitions of existing codes are changed, and codes we have memorized are often deleted and replaced. In addition, guidelines for code assignment are constantly revised and may be altered based upon individual insurance payer interpretation. Remember, a code must accurately represent the service performed, and a code that is "close" to the procedure performed cannot be assigned. If the service performed is not defined by an existing procedure code (CPT Category I, II, III or HCPCS Level II), then an unlisted procedure code must be used. The forms and guidelines to request new codes or changes to procedure code descriptors are currently located on the American Medical Association website in the "CPT Process" section (www.ama-assn.org/ama/ pub/category/3112.html).

American Medical Association↗

PubMed2000

Comparison of nurse practitioner and family physician relative work values.

PURPOSE: With the enactment of the Balanced Budget Act of 1997, American nurse practitioners were granted direct Medicare reimbursement for Part B services. Payment structures in fee-for-service and managed care systems are physician-based, leading to difficulties in constructing payments for other health care professionals. The purpose of this pilot study was to examine the feasibility of using nurse practitioner data for specifying relative work values in the Medicare Fee Schedule for three office-visit codes. DESIGN: An exploratory survey was designed to establish relative work values using magnitude-estimation scaling. Nurse practitioners (N = 43) responded to a structured questionnaire in a national mail survey. Physician data (N = 46) were obtained from a computerized database from the American Academy of Family Physicians. METHODS: The methods used in this study were the same as the process used by the American Medical Association and the Health Care Financing Administration to establish relative work values in the Medicare Fee Schedule. Respondents established relative work values for three Current Procedural Terminology (CPT) codes for office visits (99203, 99213, 99215) commonly billed in primary care practice. Each CPT code descriptor and associated vignette were compared with reference services germane to the practice of nurse practitioners and family physicians, using magnitude-estimation scaling. To establish relative work values for each code, respondents were asked to consider the time to provide the service and intensity of the work involved for each CPT code. FINDINGS: No significant differences between nurse practitioners and family physicians were found in the three CPT codes for relative work values and intensity. Nurse practitioners estimated significantly (p < .01) higher intraservice (face to face) time with patients than did family physicians, and family physicians estimated significantly (p < .05) higher pre-service time for two codes and significantly (p < .05) higher postservice times for three codes. CONCLUSIONS: Nurse practitioner relative work values did not differ significantly from family physician relative work values. Although the sample sizes were small, the significance of the findings support the need for further research with large data sets and additional CPT codes. Such studies could then be used as a basis for decisions about Medicare payment and public policy.

Humans↗

PubMed1994

How to structure clinical practice guidelines for continuous quality improvement?

The purpose of this study was to evaluate the relevance of available practice guidelines to clinical quality improvement programs. A sample of 19 guidelines was evaluated in four prominent primary care areas. Two research assistants independently coded the clinical conditions and recommended/not recommended procedures abstracted from the guidelines (Cohen's kappa .67 and .50, respectively). An average of 35.1 (+/- 25.8) medical conditions and 48.4 (+/- 41.5) clinical procedures were defined by the guidelines. Most conditions were defined by using ICD-9-CM, age/sex group, or therapy, but 29% of definitions included symptoms which are not coded routinely. CPT codes alone were unable to identify most procedures. AHCPR guidelines mentioned significantly more procedures (p < .001) and fewer symptoms (p < .001) per clinical condition than other guidelines. The difficulty of finding codes for conditions and procedures, the high rate of non-codable items, and the lack of recommended measures limit the applicability of published clinical practice guidelines to continuous quality improvement programs.

Age Factors↗

PubMed2002

Optimizing coding and reimbursement to improve management of Alzheimer's disease and related dementias.

The objectives of this study were to review the diagnostic, International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM), diagnosis related groups (DRGs), and common procedural terminology (CPT) coding and reimbursement issues (including Medicare Part B reimbursement for physicians) encountered in caring for patients with Alzheimer's disease and related dementias (ADRD); to review the implications of these policies for the long-term clinical management of the patient with ADRD; and to provide recommendations for promoting appropriate recognition and reimbursement for clinical services provided to ADRD patients. Relevant English-language articles identified from MEDLINE about ADRD prevalence estimates; disease morbidity and mortality; diagnostic coding practices for ADRD; and Medicare, Medicaid, and managed care organization data on diagnostic coding and reimbursement were reviewed. Alzheimer's disease (AD) is grossly undercoded. Few AD cases are recognized at an early stage. Only 13% of a group of patients receiving the AD therapy donepezil had AD as the primary diagnosis, and AD is rarely included as a primary or secondary DRG diagnosis when the condition precipitating admission to the hospital is caused by AD. In addition, AD is often not mentioned on death certificates, although it may be the proximate cause of death. There is only one ICD-9-CM code for AD-331.0-and no clinical modification codes, despite numerous complications that can be directly attributed to AD. Medicare carriers consider ICD-9 codes for senile dementia (290 series) to be mental health codes and pay them at a lower rate than medical codes. DRG coding is biased against recognition of ADRD as an acute, admitting diagnosis. The CPT code system is an impediment to quality of care for ADRD patients because the complex, time-intensive services ADRD patients require are not adequately, if at all, reimbursed. Also, physicians treating significant numbers of AD patients are at greater risk of audit if they submit a high frequency of complex codes. AD is grossly undercoded in acute hospital and outpatient care settings because of failure to diagnose, limitations of the coding system, and reimbursement issues. Such undercoding leads to a lack of recognition of the effect of AD and its complications on clinical care and impedes the development of better care management. We recommend continuing physician education on the importance of early diagnosis and care management of AD and its documentation through appropriate coding, expansion of the current ICD-9-CM codes for AD, more appropriate use of DRG coding for ADRD, recognition of the need for time-intensive services by ADRD patients that result in a higher frequency of use of complex CPT codes, and reimbursement for CPT codes that cover ADRD care management services.

Aged↗

PubMed2000

Know difference between APC coding systems.

You'll need to revise your chargemasters to include all of the evaluation and management CPT codes for emergency and clinic technical services to prepare for the Health Care Financing Administration's switch to ambulatory payment classifications for outpatient services. Physician- and hospital-generated CPT codes present different challenges. Physician CPT coding should never be performed on the higher-level visits without complete documentation of the higher-level visits. A descriptive patient classification system (PCS) does not accurately portray the intensity of the visit, but the quantified PCS lists specific nursing tasks and assigns a point value to each one.

Abstracting and Indexing↗

PubMed2026

Can ChatGPT Replace Human Clinical Coders? A Comparative Study in Otology Billing.

OBJECTIVE: Evaluate the utility of the large language model (LLM), ChatGPT, for the analysis of operative notes and the generation of Current Procedural Terminology (CPT) codes in comparison to human clinical coders. STUDY DESIGN: CPT billing codes assigned by ChatGPT were compared to existing billing data. Otology practice within a tertiary academic center. METHODS: About 191 operative notes from a single surgeon (9/2022-10/2023) were analyzed. ChatGPT-3.5 and 4 models were prompted for CPT codes based on operative notes. Assessment included determining exact and partial match rates, sensitivity and specificity for targeted procedures, and work Relative Value Units (wRVU) differences between ChatGPT-generated and human-assigned codes. RESULTS: ChatGPT-3.5 achieved exact matches in 22% of cases and partial matches in 32%, while ChatGPT-4 achieved 14% exact and 33% partial matches. When cochlear implantation (CI) was excluded, performance dropped significantly. For CI, ChatGPT-3.5 demonstrated a sensitivity of 94% and specificity of 90%, while ChatGPT-4 showed a sensitivity of 96% and specificity of 92%. In contrast, performance on cartilage grafting was poor, with sensitivities of 4.2% for ChatGPT-3.5 and 0% for ChatGPT-4. ChatGPT-3.5 and 4 showed moderate CPT code matching accuracy among themselves, with slight agreement to human coders. Both models tended to underbill for wRVUs compared to human coders, with significant differences in the values generated. CONCLUSION: This study assessed ChatGPT's effectiveness in automating CPT code assignment for otologic surgeries. While the models achieved high sensitivity values for assigning codes related to cochlear implantation, both models struggled with complex cases, failed to apply modifiers, and often assigned fewer wRVUs. The findings highlight ChatGPT's potential in medical billing but indicate a need for further refinement.

Humans↗

PubMed2005

The new apheresis and blood and marrow transplantation-related current procedural terminology codes for payment of apheresis and blood and marrow transplantation services.

To address deficiencies in Current Procedural Terminology (CPT) codes that describe many of the clinical services offered to patients, several physicians in the blood and marrow transplantation and apheresis field joined with a coalition including the American Society of Hematology, American Society for Blood and Marrow Transplantation, American Association of Blood Banks, American Society of Clinical Oncology, American Society for Apheresis, National Marrow Donor Program, and American Red Cross to collaborate in addressing these deficiencies by designing new CPT codes. The CPT editorial panel approved 18 new or revised codes. All these codes were given permanent or temporary value by the relative value unit update committee, but not all values were approved by the Centers for Medicare & Medicaid Services (CMS), in particular, the cell-processing codes and the unrelated donor search code. Further discussions addressing these concerns are under way with the CMS. Use of these new codes allows apheresis and transplant centers to charge appropriately for these services. This will help transplant center contracts with CPT codes, with payers more specifically describing services offered to these patients. In turn, this will give better justification for payment. This may allow certain payments for services to increase and help transplant centers better allocate revenue from fixed global case rate payments. Details about the individual codes and their approval process are reviewed in this article.

Blood Component Removal↗

PubMed2003

Interventional pain management: evolving issues for 2003.

The new millennium has seen the introduction of an array of new Current Procedural Terminology(R) (CPT) codes and the expansion of interventional techniques. Among the many issues of interest to physicians practicing interventional pain management in 2003 are CPT coding, correct coding issues, and utilization. The CPT developed and updated by the American Medical Association, is the most important and commonly used coding system for interventional pain physicians in the United States. A recent development in the CPT system has been to include Category I, Category II, and Category III CPT codes. Inclusion of a code in Category I is generally based on the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. In contrast, CPT Category III, also known as emerging technology codes, is a set of temporary codes for emerging technology, services, and procedures. There have been many new codes since 2000, along with changes in the definitions of the codes and vignettes. In order for the correct coding initiative to be effective, it is essential that the coding describes what actually transpires at each patient encounter. When multiple procedures are performed at the same session, the procedure and post-procedure work do not have to be repeated for each procedure, and, therefore, a comprehensive code describing the multiple services commonly performed together can be used. Thus, many activities which are integral to a procedure are considered as generic activities and are assumed to be included as acceptable medical/surgical practice and, while they couldn't be performed separately, they should not be considered as such when a code narrative is defined. Under this initiative, almost all interventional techniques are affected. The utilization of interventional techniques in the modern era is the final issue. Utilization has been increasing gradually. Thus, it is important for interventional pain physicians to understand the utilization patterns across the nation and for various techniques. This review will discuss the issues of CPT coding, correct coding, and utilization as they pertain to interventional techniques.

Journal Article↗

PubMed2001

Measuring the academic radiologist's clinical productivity: applying RVU adjustment factors.

RATIONALE AND OBJECTIVES: To improve understanding of academic radiologists' clinical workloads, the Society of Chairmen of Academic Radiology Departments (SCARD) performed surveys to collect workload data for radiologists in 20 departments; workload was measured in relative value units (RVUs) per full-time equivalent (FTE). Although they were useful for comparisons within some subspecialties, the workload data proved inadequate for comparisons across sections, and adjustment factors were needed for each Current Procedure Terminology (CPT) code. MATERIALS AND METHODS: All CPT codes for examinations were divided into groups with similar radiologist work effort. Focusing on radiologists who worked almost exclusively in each group, the authors created adjustment factors by using data from the individual radiologists at each institution. RESULTS: The adjustment factors are 0.50 for angiography, 0.58 for computed tomography and magnetic resonance imaging, and 1.0 for nuclear medicine, plain radiography, and special procedures (no adjustment needed for these groups). These factors are multiplied by the work RVUs for each examination to create the adjusted workload RVUs. CONCLUSION: The SCARD survey provided very useful clinical workload data, with workload measured in work RVUs per FTE for specific subspecialty sections. The new adjusted workload RVUs allow comparison of radiologists' workload across subspecialties.

Academic Medical Centers↗

PubMed2002

Telemedicine versus in-person dermatology referrals: an analysis of case complexity.

The goal of this study was to determine whether teledermatology referrals differ significantly from in-person referrals with respect to case complexity and diagnosis of cases referred. Teledermatology cases were compared to in-person cases seen by the same university dermatologist who also reviews the teledermatology cases. These were also compared with in-person cases evaluated by a different dermatologist at local clinics using traditional referral patterns. Study parameters included Current Procedural Terminology (CPT) codes as a measure of case complexity, International Classification of Disease (ICD) codes as a measure of case types, and time from referral to actual consultation. The most common CPT codes used for teledermatology were 99241 and 99242 with no significant differences in the frequency of assigned CPT codes for teledermatology versus in-person consultation. An analysis of the diagnostic codes revealed no significant differences between the types of cases referred to telemedicine and those referred for in-person consultation. Time between referral and actual encounter with the dermatologist was significantly shorter via telemedicine than either local or university clinic in-person visits.

Chi-Square Distribution↗

PubMedDate not supplied

Survey of the degree to which ET nurses are performing current procedural terminology-coded services.

ET nurses practice in many different settings including hospitals, home health, independent practice, and contract services. Reimbursement for their services is widely varied. To contribute meaningfully to health care reform, the services being provided by ET nurses must be identified. Familiarity with how these services overlap with those provided by other health care providers is essential. Current Procedural Terminology (CPT) codes, the language of payment within the health care system, are prepared and published annually by the American Medical Association for purposes of physician payment. Physicians are being paid for services that are also performed by ET nurses. This study identifies the CPT-coded services used in the practice of the ET nurse and also codes that overlap those for which physicians are paid. Identification of ET nurse-provided CPT-coded services delineates the ET nursing scope of practice and may serve as a foundation to address other practice issues, including reimbursement.

Abstracting and Indexing↗

PubMed2006

Insurance barriers for childhood survivors of pediatric brain tumors: the case for neurocognitive evaluations.

OBJECTIVE: The purpose of the present study was to provide empirical evidence of system-based barriers to psychological services for pediatric brain tumor patients when they are medically indicated. METHOD: Insurance claims data covering 263,866 insured lives during the 1996 fiscal year were pooled from a cross-sectional national sample of adults and their families insured by private insurance companies or self-insured firms. Based on inclusion criteria, records for 209 pediatric brain tumor patients aged 18 and under were extracted and analyzed. Claims data including total amount of payments made on behalf of a member, total length of hospital stays, and total number of unique admissions were recorded for all patients, and current procedural terminology (CPT) codes were analyzed to determine frequency of payment for routinely billed psychological procedures. Results were then compared to the frequency of payment for routinely billed psychological procedures for children with other medical conditions. RESULTS: Results indicate that two of the CPT codes commonly associated with neurocognitive evaluations were reimbursed by these third-party payers for pediatric brain tumor patients during the 1996 fiscal year. Additionally, seven of the CPT codes commonly associated with psychological therapy were also reimbursed. CONCLUSIONS: The present findings provide empirical evidence of system-based obstacles (i.e., lack of third-party reimbursement) for medically indicated psychological services in pediatric brain tumor patients.

Brain Neoplasms↗

PubMedDate not supplied

Access to orthopaedic care for children with medicaid versus private insurance: results of a national survey.

BACKGROUND: It has been documented that children insured by Medicaid in California have significantly less access to orthopedic care than children with private insurance. Low Medicaid physician reimbursement rates have been hypothesized to be a major factor. The first objective of this study was to examine whether children insured by Medicaid have limited access to orthopedic care in a national sample. The second objective was to determine if state variations in Medicaid physician reimbursement rates correlate with access to orthopedic care. METHODS: Two-hundred fifty orthopedic surgeon's offices, 5 randomly chosen in each of 50 states, were telephoned. Each office called was asked to answer questions to an anonymous, disclosed survey. The survey asked whether the office accepted pediatric patients, whether they accepted children with Medicaid, and whether they limited the number of children that they accepted with Medicaid, and if so why. Each state sets its own rate of physician reimbursement rates that were collected from individual state Medicaid agencies for 3 different CPT codes. The relationship between acceptance of patients with Medicaid and the individual state's Medicaid reimbursement rate was examined. RESULTS: Children with Medicaid insurance had limited access to orthopedic care in 88 of 230 (38%) offices that treat children, and 18% (41/230) of offices would not see a child with Medicaid under any circumstances. Reimbursement rates for CPT codes widely varied by state: 99243 for an outpatient consultation (range, $20-$176.38), 99213 for an established follow-up outpatient visit (range, $6-$77.76), and 25560 for global treatment of a nondisplaced radius and ulna shaft fracture without manipulation (range, $50-$403.94). There was a statistically significant relationship between access to medical care for Medicaid patients and physician reimbursement rates for all 3 CPT codes. CONCLUSIONS: Children insured with Medicaid have limited access to orthopedic care in this nationwide sample. Medicaid physician reimbursement significantly correlates with patient access to medical care. These data may be of value in the ongoing efforts to improve access to medical care for children on Medicaid. The logical inference from this study is that increasing physician reimbursement rates will improve access. In the authors' opinion, reimbursement rates should be made higher than office overhead to effect meaningful change.

Child↗

PubMedDate not supplied

The costs of CT procedures in an academic radiology department determined by an activity-based costing (ABC) method.

PURPOSE: The purpose of this work was to determine the costs of computed tomography (CT) procedures in a large academic radiology department, including both professional (PC) and technical (TC) components, by analyzing actual resource consumption using an activity-based costing (ABC) method and comparing them with Medicare payments. METHOD: Over a 12 month period from July 1, 1996, to June 30, 1997, 1,011 CT procedures, representing 16 Physicians' Current Procedural Terminology (CPT) codes and 98.3% of CT studies performed, were carefully observed by a research assistant trained in ABC methodology. Information collected during these time and motion studies included personnel/machine time and direct materials used. Actual resource units used during the different activities in each CT procedure were valued using appropriate cost drivers. Unit values for both direct and overhead costs were calculated: the cost of an individual procedure equaled the sum of component costs. Costs were compared with PC and TC payments according to the 1997 Medicare Fee Schedule. RESULTS: Total costs of CPT codes 70450 (CT Head unenhanced), 71260 (CT Chest enhanced), and 74160 (CT Abdomen enhanced), which represented 71.2% of CT studies performed, were $189.19, $273.53, and $343.20, respectively. For all 16 nonmodified CPT codes analyzed, Medicare's professional reimbursement was less than the professional cost, whereas its technical reimbursement exceeded respective cost in 14 of the 16 codes. CONCLUSION: In the setting and time period studied, Medicare underreimbursed professional costs while overreimbursing technical costs.

Academic Medical Centers↗

PubMedDate not supplied

Medication therapy management services: a critical review.

OBJECTIVE: To identify and examine medication therapy management (MTM) practice and compensation models currently being used by public and private sector programs, develop a model for payers to consider in compensating pharmacists for the provision of MTM services, and review how a relative value-based payment system based upon Current Procedural Terminology (CPT) codes might apply to MTM services. DATA SOURCES: Peer-reviewed literature; study of existing MTM practice and compensation models; interviews with pharmacists, pharmacy benefit providers, health plans, and policy makers; structured discussions with industry experts. SUMMARY: Implementation of MTM represents an opportunity for pharmacists to provide public and private payers with examples of service packages and business models that improve patient therapeutic outcomes. MTM services can lead to overall cost reductions and improved health outcomes. Recommendations for pharmacists, health plans, and Medicare Part D prescription drug plan sponsors are provided. Pharmacists should standardize and package MTM services at varying levels of intensity; determine work values for MTM CPT codes, use standards for billing and service delivery, build supply capacity to meet demand for MTM services, and cultivate patient and provider support for pharmacist-provided MTM services. Plans and sponsors should develop mechanisms for measuring MTM impact on overall health care costs and develop payment systems to cover costs as well as sustain and provide for growth in the number of providers. CONCLUSION: The essential components of MTM business and payment models, as outlined in this article, can be effectively mapped to relative value-based CPT codes for pharmacist-provided MTM services. Pharmacy providers, after considering various factors and conditions in their own environment, can develop an optimal MTM service package and business model based on this information.

Drug Therapy↗

PubMedDate not supplied

Coding for endocrine services: using the new codes and the evocative/suppression testing protocols.

In 1994, a series of new current procedural terminology (CPT) codes for the description of services provided primarily by clinical endocrinologists were approved. Included were codes for 22 new endocrine evocative/suppression testing panels that represent the laboratory analyte portions of a series of endocrine protocols. These new codes were to be used in conjunction with another series of new codes for the physician's services, called prolonged physician services. These two new series of CPT codes are discussed in this article, and useful examples of their application, not described elsewhere to date, are provided.

Journal Article↗

PubMed2003

Are there disparities in emergency care for uninsured, medicaid, and privately insured patients?

OBJECTIVES: To determine if there are any differences in proportion of high-acuity care and low-acuity care provided to uninsured, Medicaid-insured, and privately insured emergency department (ED) patients. METHODS: This was a retrospective, observational study using physician level of service provided as a marker for acuity. The study used computerized billing data (2000-2001) from an urban, teaching, Level I trauma center with 75,000 visits per year. All uninsured and Medicaid patients (age groups: pediatric, <18 years; adult, 18-64 years) were compared by physician level of service billed to Blue Cross-Blue Shield (BCBS) patients and analyzed using chi-square. Low-acuity care was defined by CPT codes 99281 and 99282. High-acuity care was defined by CPT codes 99285 and 99291. RESULTS: There were 152,379 total ED visits, with 13.2% BCBS (5,273 pediatric, 14,951 adult), 29.6% Medicaid (20,578 pediatric, 24,511 adult), and 8.1% uninsured (1,879 pediatric, 10,405 adult) patients. The percent of pediatric BCBS, Medicaid, and uninsured patients receiving low-acuity care was 30%, 35.7%, and 35.8% (p < 0.001), respectively; and for high-acuity care, it was 7.8%, 6.1%, and 6.8% (p < 0.001), respectively. The proportion of adults within these groupings was 13.7%, 13.2%, and 17.9% (p < 0.001) for low-acuity care, and 28.5%, 22.9%, and 16.7% (p < 0.001) for high-acuity care, respectively. CONCLUSIONS: Whereas there were some statistically discerned differences between insurance groupings for proportionate receipt of low-acuity care and high-acuity care among both the pediatric and adult populations, the magnitude of most differences noted was not large, and may not reflect important differences in health care need or ED use based on insurance.

Adolescent↗