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PubMed2006

The use of the Soterion Rapid Triage System in children presenting to the Emergency Department.

There has been a recent move toward the adoption of five-level triage systems in the United States. However, there have been no studies in this country that have critically evaluated the use of these systems in children. The purpose of this study was to evaluate the reliability and validity of a new five-level triage system, the Soterion Rapid Triage System, for stratifying acuity levels in children under the age of 13 years. The study was conducted in a 389-bed Level II mixed adult and pediatric Trauma Center that experiences approximately 12,000 patient visits/year of children under the age of 13 years. We performed a prospective evaluation of the system's reliability using the weighted kappa statistical method (n = 117) and a retrospective evaluation of the system's validity through an analysis of all patients under the age of 13 years triaged with the system over an 8-month period (n = 7077). The system's validity was measured by in-hospital admission rate, Emergency Department length of stay, hospital charges, and Current Procedural Terminology (CPT) Codes 99281-99285. The inter-rater reliability as measured by the weighted kappa was 0.90 (95% confidence interval 0.83-0.96), with 92% exact agreement between nurses in the triage level assigned. The in-hospital admission rates for patients triaged as Level 1 Immediate-Level 5 Non-Urgent were 38%, 18%, 9%, 1.5% and 0.4%, respectively (p < 0.0001). The mean total hospital charges for each of the five triage levels were $2673, $1563, $1112, $477, and $258, respectively (p < 0.0001). Similarly, there were significant differences in the means for laboratory and pharmacy charges, Emergency Department lengths of stay, and CPT Codes. This report represents the first study in this country on the effectiveness of a five-level triage system in children. We have demonstrated that the Soterion Rapid Triage System possesses high inter-rater reliability and validity when used to triage children younger than 13 years of age.

Algorithms↗
PubMed1990

A computerized approach to injury description.

The study of trauma has been handicapped from its inception by the absence of a single coherent method of cataloging injuries. The AIS and ICD-9 systems have failed to fill this void because they lack the precision necessary to describe surgically treated injuries. We conceived a simple system of injury description in which injuries are rapidly encoded using a microcomputer in sufficient detail to distinguish among millions of different injuries. This system is easily searched by a microcomputer and allows for the automatic assignment of AIS, ISS, and CPT codes. In this system a patient is described by a 'paragraph' consisting of any number of identically patterned 'sentences,' each describing one of the patient's injuries. Each 'sentence' is composed of a string of six 'words' from controlled vocabularies and has the following structure: "Body region, Organ, Anatomic region, Injury, Physiology, Treatment." Defining the vocabulary allowed for each 'word' in a 'sentence' is complex because the allowed vocabulary is dependent upon the preceding 'words' in a 'sentence,' but in practice a microcomputer simply provides short lists of acceptable choices at each step of injury description, and records the user's selections. Additionally, the microcomputer assigns AIS, ISS, and CPT codes appropriate to the injury description sentence. The ease of data entry, the fineness of detail captured, the automation of code assignment, and the accuracy of database searching for specific injuries, classes of injuries, or combinations of injuries, we believe will give this approach widespread application in academic trauma centers where an accurate and accessible trauma database is important.

Humans↗
PubMed2003

National Academy of Neuropsychology/Division 40 of the American Psychological Association Practice Survey of Clinical Neuropsychology in the United States. Part II: Reimbursement experiences, practice economics, billing practices, and incomes.

Leaders of the National Academy of Neuropsychology and Division 40 (Clinical Neuropsychology) of the American Psychological Association determined that current information on the professional practice of clinical neuropsychology within the United States was needed. These two organizations co-sponsored a national survey of U.S. clinical neuropsychologists that was conducted in September 2000. The primary goal of the survey was to gather information on such topics as: practitioner and practice characteristics, economic variables (e.g., experience with major third party payors, such as Medicare and managed care), practice expenses, billing methods, experiences with Current Procedural Terminology (CPT) codes, time spent on various clinical tasks, use of assistants, and income. In this second of two articles describing the survey results, reimbursement experiences, practice economics, billing practices, and incomes are highlighted. Survey results indicate that neuropsychologists frequently have difficulty gaining access to membership on managed care panels. For those who gain access, managed care companies often limit provision of services; this is quite often perceived as negatively affecting quality of patient care. It is very common for neuropsychologists to feel obligated to provide more services to managed care and Medicare patients than are allowed to be billed to the insurance carrier; these hours are typically "written off." Numerous CPT codes are used to bill the same clinical service. Awareness of Medicare practice and billing expectations is variable among practitioners, as is awareness of public aid/Medicaid billing status. Professional income is influenced by years of licensed practice, practice setting, gender, types and amounts of non-clinical professional activities, and types and amounts of reimbursement sources within one's clinical practice. Income of neuropsychologists has only a minimal relationship to percentage of clinical practice per week. Within the context of prior surveys, neuropsychologists are engaging in more clinical hours per week and, nevertheless, compared to data from 1993, are reporting decreased income. These and other findings are presented and discussed.

Academies and Institutes↗
PubMedDate not supplied

Health care resources and costs for treating peripheral artery disease in a managed care population: results from analysis of administrative claims data.

OBJECTIVE: Peripheral arterial disease (PAD) is associated with high rates of morbidity and mortality and serves as an important marker for advanced systemic atherosclerosis accompanied by symptomatic or asymptomatic ischemia of the coronary, cerebral, and visceral vasculature. There are little published data on the use of health care resources and costs attributable to PAD. The objectives of this study were to evaluate, from a societal perspective, PAD-related health care resource utilization and to determine the total annualized costs and cost components for patients with PAD, with particular attention to the key outcomes of myocardial infarction (MI), transient ischemic attacks (TIA), stroke, and amputations. METHODS: This study examined medical, hospital and outpatient, and pharmacy claims from a large managed care database with dates of service from January 1, 1999, through August 31, 2003. Patients with PAD were identified from claims using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes (primary or secondary codes), ICD-9-CM procedure codes, current procedural terminology (CPT) codes, or by a pharmacy claim for cilostazol or pentoxifylline. The index date for each patient was the first occurrence of either a medical claim for PAD or a pharmacy claim for 1 of the 2 drugs. Patients were required to be a minimum of 18 years old with continuous plan eligibility. The prevalence of PAD in adults in a managed care setting was also determined, as were annual rates for the key outcomes of MI, TIA, stroke, and amputations. Health care resource utilization and costs were calculated for PAD patients after the index date for a period of at least 12 months per patient for medications, outpatient/physician office visits, laboratory/diagnostic procedures, emergency department visits, and hospitalization. Cost was defined as the allowed charge on each administrative claim, including the amount paid by the insurer plus the amount paid by the health plan members (copay, deductible, and coinsurance). RESULTS: Prior to application of exclusion criteria for patients aged 18 years or older and the minimum period of continuous eligibility, the overall prevalence of PAD was 1.18% of the total managed care organization population.s 6.67 million members. The PAD study cohort consisted of 30,561 patients with a mean age of 70.7 years at index. The most common comorbidities identified in the preindex period for these PAD patients included hypertension (67% of patients); metabolic disorders/hypercholesterolemia (57%); heart disease including cardiomyopathy, dysrhythmias, and heart failure (55%); and ischemic heart disease (47%). Over a mean postindex period of 25.2 months (median 23.4 months), the total mean annualized PAD-related cost was $5,955 per patient per year (PPPY). Hospitalizations accounted for the largest component cost category, averaging $4,442 PPPY or 75% of the total annualized PAD-related cost per PAD patient. PAD-related noncoronary procedures averaged $729 PPPY (12.2% of total annual PAD-related costs), and PAD-related medications (including antihypertensives and lipid-lowering therapy) totaled $610 (10.2% of total annual costs), including $313 PPPY for antihypertensives and $207 for lipid-lowering therapy. For the subgroup of 24,075 newly identified PAD patients, 8,479 (35.2%) were hospitalized during an average 25.2 months of follow-up, with the mean time to first hospitalization of 8.9 months. CONCLUSIONS: Approximately 75% of the total PAD-related patient cost in an average of 25 months of follow-up is contributed by hospital costs, and 35% of patients newly diagnosed with PAD experienced a hospitalization in a mean of 8.9 months after the index diagnosis. Based upon mean annual health and member costs of only $313 PPPY for antihypertensives and $207 for lipid-lowering therapy, drug therapy in PAD patients may be underutilized.

Aged↗
PubMedDate not supplied

Genetic testing coverage and reimbursement: a provider's dilemma.

The rapid growth of new molecular genetic tests stimulated by the diagnostic potential of DNA/RNA analyses has resulted in the capability of molecular genetic assay technology outpacing the American Medical Association Current Procedural Terminology (CPT) codes and Medicare reimbursement. The AMA CPT Editorial Panel is poised to change the way we report genetic testing, and this change may have the potential to stimulate a governmental review of how Medicare is paying for diagnostic genetic testing. Genetic assays are costly, and those in laboratory management need to be aware of potential changes that may influence the ability of their laboratory to provide access to genetic testing services for their physician clientele. The commercialization of genetic testing has resulted in a proliferation of commercial laboratories and university medical center laboratories, CLIA-certified to perform high complexity testing, offering some level of genetic testing. The genetic tests are offered as home brew (in-house developed) assays, most of which are using analyte-specific reagents. Because these are home brew assays, there is no standardization in how the industry tests for specific mutations. As these genetic assays are billed using the generic molecular diagnostic codes, 83890 through 83912, from the Pathology and Laboratory Chemistry subsection of the CPT, payers are not able to identify the specific mutations being tested and make payment determinations based on the mutations as they relate to the diagnosis code. This article discusses the history of molecular diagnostic coding and related reimbursement, current coverage issues, and the genetic coding proposal under consideration by the AMA CPT Editorial Panel.

Centers for Medicare and Medicaid Services, U.S.↗
PubMedDate not supplied

And still more new codes.

Before reporting the new Category III CPT codes, contact payors to determine both acceptance of these temporary codes and reimbursement allowances. Documentation must clearly support all services performed, and the requirements for an online medical evaluation should be followed, with the encounter recorded in the individual patient medical record. Hospitals should also review the quarterly changes to OPPS codes and descriptors and ensure that Charge Description Masters are updated as new codes become effective.

Ambulatory Care↗
PubMed2006

A compliance focus on the 2006 OIG Work Plan.

To determine which areas of professional billing present the highest risk to your practice, it is recommended that physicians and their office staff review the Office of Inspector General's (OIG) annual Work Plan. The Work Plan details areas for increased scrutiny by the federal government due to a high rate of inappropriate billing, which has cost the Medicare program millions of dollars. The OIG's Work Plan for Fiscal Year 2006 identifies several new areas of investigation, but what is more curious is what is not on the OIG Work Plan for 2006. For the first time in several years, this year's Work Plan does not include investigations into evaluation and management services (E/M), including the controversial consultation codes. But don't let your guard down on E/M documentation as our local Medicare carrier has stated they will begin a widespread probe review into the hospital admit CPT code 99222. Documentation to support the billing of CPT 99222 must include a comprehensive history (including ten review of systems); a comprehensive examination of eight or more organ systems for the 1995 guidelines or two elements from each of nine systems of a 1997 multisystem exam; and moderate decision making. Medicare will also be requesting reviews on subsequent inpatient hospital care codes, CPT 99231, 99232 and 99233.

Fees, Medical↗
PubMed2002

Role of a medical staff coding committee in documentation, coding, and billing compliance.

Physician documentation, Current Procedural Terminology (CPT) coding, and compliance with federal billing regulations are essential given the government's significant efforts to address fraud and abuse and the grave financial and legal consequences of noncompliance. Because Medicare guidelines do not focus substantially on psychiatric care, compliance is especially challenging for psychiatrists and psychiatric centers. Four years ago, the University of Texas-Harris County Psychiatric Center formed a medical staff coding committee to assist the center and its psychiatrists in dealing with compliance issues. The committee has evolved into a highly effective and important component of the institution's overall compliance program. The authors discuss the origins, development, and accomplishments of the medical staff coding committee.

Documentation↗
PubMed2005

New coding and billing opportunities for 2005--Part II.

Part I of this series highlighted several changes in preventative care services and additional revisions for pediatricians, orthopedists, endoscopist and surgeons performing transplants and bariatric surgery. Part II addresses several new codes in gynecology, orthopedics, neurosurgery, and ophthalmology. It also includes wound care along with many revisions within chemotherapy for Medicare patients. All new CPT codes should have been activated and deleted codes discontinued effective for dates of service on or after January 1, 2005. From that date forward the patient's date of service must reflect current diagnosis (ICD-9) and procedure/services (CPT and HCPCS) codes.

Current Procedural Terminology↗
PubMed2005

Clinical services provided by interventional radiologists to Medicare beneficiaries in the United States, 2000-2003.

To identify trends in Evaluation and Management (E&M) and non-E&M services of interventional radiologists (physician specialty type 94) from 2000 to 2003 for Medicare patients, Medicare Part B physician annual allowed services data from the Centers of Medicare and Medicaid Services (CMS) were analyzed for all interventional radiologists from 2000 to 2003. Because the number of interventional radiologists in the United States according to the Society of Interventional Radiology is, on average, 4.2 times the number of interventional radiologists who use physician specialty type 94, we extrapolated the E&M services for each year. During the period examined, the total number of E&M services by interventional radiologists increased 309%, from 9,698 in 2000 to 29,914 in 2003. The most commonly performed services were Office or Other Outpatient Visit (Current Procedural Terminology [CPT] codes 99211-99215) for established patients, followed by Subsequent Hospital Care (CPT 99231-99233) and Office or Other Outpatient Consultations (CPT 99241-99245). The extrapolated number of E&M services by interventional radiologists for Medicare patients in 2003 is approximately 107,853. The number of Office and Outpatient Visits for New Patients (CPT 99201-99205) increased 142%, whereas the number of Consultations for New Patients (CPT 99241-99245) increased 208%. The total number of codes reimbursed by CMS to interventional radiologists (type 94) increased from 2.8 million in 2000 to 3.8 million in 2003.

Current Procedural Terminology↗
PubMed1992

Predicting the work of evaluation and management services.

Physicians, carefully adhering to the definitions of Physicians' Current Procedural Terminology (CPT) billing codes, used the same CPT codes to denote evaluation and management services that varied widely in work and used different codes for services whose work was the same. As payment shifted to the Medicare Fee Schedule, it was important that the coding system be redefined so that codes consistently reflect the resource costs of these services. Redefining these codes for a resource-based payment system required an understanding of how verifiable predictors relate to physician work. Using data obtained from the Resource-Based Relative Value Scale (RBRVS) study regarding 377 services surveyed among physicians in 31 specialties, multiple regression analyses of the relationship of different variables to the mean values of work were performed. Intraservice time, which accounted for 90% of the variance, was the most important predictor of intraservice work. Specification of time, which previously had not been an element in the definitions of CPT codes for evaluation and management services, was useful in refining these codes so that their value corresponds more closely to resource costs. Other predictors of work were site of service or visit type, patient status (new/initial, established/subsequent), and referral status (consultation, nonconsultation).

Abstracting and Indexing↗
PubMed2005

Minding your business.

There are a number of ways that hospitals can enhance financial perfomance from their outpatient physical therapy services: Provide training for therapists on Medicare's "eight minute rule". Differentiate between service-based and time-based CPT codes on the charge ticket. Have a professional review CPT documentation before charges are submitted. Implement a program to prevent and manage no-shows and cancellations. Match staffing level with productivity. Pay careful attention to detail when documenting plans of care and preparing daily treatment notes.

Financial Management, Hospital↗
PubMed2004

Correct coding for laboratory procedures during assisted reproductive technology cycles.

New Current Procedural Terminology (CPT) codes for 2004 have been adopted for utilization with assisted reproductive technologies. It is important for professionals in the field of assisted reproductive technology (ART) to become familiar with them prior to their implementation. This document replaces the July 2002 American Society for Reproductive Medicine (ASRM) Practice Guideline Correct Coding for Laboratory Procedures During Assisted Reproductive Technology.

Clinical Laboratory Techniques↗
PubMed2004

Correct coding for laboratory procedures during assisted reproductive technology cycles.

New Current Procedural Terminology (CPT) codes for 2004 have been adopted for utilization with assisted reproductive technologies. It is important for professionals in the field of assisted reproductive technology (ART) to become familiar with them prior to their implementation. This document replaces the July 2002 American Society for Reproductive Medicine (ASRM) Practice Guideline Correct Coding for Laboratory Procedures During Assisted Reproductive Technology.

Cell Culture Techniques↗
PubMed2006

Correct coding for laboratory procedures during assisted reproductive technology cycles.

New Current Procedural Terminology (CPT) codes for 2004 have been adopted for utilization with assisted reproductive technologies. It is important for professionals in the field of assisted reproductive technology (ART) to become familiar with them prior to their implementation. This document replaces the July 2002 American Society for Reproductive Medicine (ASRM) Practice Guideline Correct Coding for Laboratory Procedures During Assisted Reproductive Technology.

Clinical Laboratory Techniques↗
PubMed2006

Billing effectively with the new health and behavior current procedural terminology codes in primary care and specialty clinics.

The health and behavior current procedural terminology (CPT) codes introduced in 2003 have gained nationwide acceptance through Medicare and limited acceptance through third party payers. The codes facilitate accurate description and quantification of behavioral medicine services within a primary care or specialty clinic setting. The author reviews their appropriate utilization to enhance reimbursement and facilitate development of self-sustaining behavioral medicine programs. Information is provided on increased use and reimbursement of codes within psychology. Future directions for continued advocacy, increased acceptance, training, and research are discussed.

Behavioral Medicine↗