Preoperative Criteria Predict Operative Time Variability Within Tympanoplasty Procedures

Does CPT Modifier 22 Appropriately Reflect a Difficult Pancreaticoduodenectomy? Retrospective Analysis of Operative Outcomes and Cost

BACKGROUND

CPT coding allows addition of a 2-digit modifier code to denote particularly difficult procedures necessitating additional reimbursement, called the modifier 22. The use of modifier 22 in relation to pancreatic surgery and outcomes, specifically pancreaticoduodenectomy (PD), has not been explored.

STUDY DESIGN

All PDs performed from 2010 to 2019 at a quaternary healthcare system were analyzed for differences in preoperative characteristics, outcomes, and cost based on the use of modifier 22. Adjusted logistic regression analysis was used to identify factors predictive of modifier 22 use.

RESULTS

A total of 1,284 patients underwent PD between 2010 and 2019; 1,173 with complete data were included, of which 320 (27.3%) were coded with modifier 22. Patients coded with modifier 22 demonstrated a significantly longer duration of surgery (365.9 ± 168.4 vs 227 ± 97.1; p < 0.001). They also incurred significantly higher cost of index admission ($37,446 ± 34,187 vs $28,279 ± 27,980; p = 0.002). An adjusted multivariable analysis (specifically adjusted for surgeon variation) revealed duration of surgery (p < 0.001), neoadjuvant chemotherapy (p = 0.039), class II obesity (p = 0.019), and chronic pancreatitis (p = 0.005) to be predictive of modifier 22 use.

CONCLUSIONS

Despite the subjective nature of this CPT modifier, modifier 22 is an appropriate marker of intraoperative difficulty. Preoperative and intraoperative characteristics that lead to its addition may be used to further delineate difficult PDs.

Endoscopic Versus Microscopic Pediatric Tympanoplasty: Is There a Difference Between Closure Rates and Hearing Outcomes?

OBJECTIVE

To compare closure rates and hearing outcomes of microscopic and endoscopic tympanoplasty in pediatric patients.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary university medical center.

PATIENTS

Pediatric patients who underwent tympanoplasty surgery by a fellowship-trained neurotologist between 2010 and 2019 with a minimum of 2 months of follow-up, a tympanic membrane perforation, and no preoperative cholesteatoma.

INTERVENTIONS

Transcanal endoscopic tympanoplasty or microscopic tympanoplasty (MT) surgery.

MAIN OUTCOME MEASURES

The primary outcome is postoperative closure of the tympanic membrane perforation, assessed using otomicroscopy at the last follow-up appointment. Secondary outcomes include operative time and changes in the air-bone gap (ABG) and pure-tone average (PTA).

RESULTS

Two hundred eleven tympanoplasty operations were analyzed: 121 in the transcanal endoscopic ear surgery (TEES) group and 90 in the MT group. Tympanic membrane closure rates were no different between the two groups (TEES, 82.6%; MT, 88.9%; p = 0.24), and no significant association was found on multivariable analysis (TEES: odds ratio, 0.8; p = 0.61). Both groups showed improvements in the 4-month PTA and ABG and the 12-month PTA, but the 12-month ABG only improved in the TEES group ( p < 0.01). The TEES group had a shorter average operative time (109.8 versus 123.5 min; p = 0.03) and less need for a postauricular incision (2.5% versus 93.3%; p < 0.01).

CONCLUSION

In pediatric tympanoplasty, TEES gives similar membrane closure and hearing outcomes as the microscopic technique, with less operative time and less need for a postauricular incision.