Systematic evaluation of common natural language processing techniques to codify clinical notes

Proper codification of medical diagnoses and procedures is essential for optimized health care management, quality improvement, research, and reimbursement tasks within large healthcare systems. Assignment of diagnostic or procedure codes is a tedious manual process, often prone to human error. Natural Language Processing (NLP) has been suggested to facilitate this manual codification process. Yet, little is known on best practices to utilize NLP for such applications. With Large Language Models (LLMs) becoming more ubiquitous in daily life, it is critical to remember, not every task requires that level of resource and effort. Here we comprehensively assessed the performance of common NLP techniques to predict current procedural terminology (CPT) from operative notes. CPT codes are commonly used to track surgical procedures and interventions and are the primary means for reimbursement. Our analysis of 100 most common musculoskeletal CPT codes suggest that traditional approaches can outperform more resource intensive approaches like BERT significantly (P-value = 4.4e-17) with average AUROC of 0.96 and accuracy of 0.97, in addition to providing interpretability which can be very helpful and even crucial in the clinical domain. We also proposed a complexity measure to quantify the complexity of a classification task and how this measure could influence the effect of dataset size on model's performance. Finally, we provide preliminary evidence that NLP can help minimize the codification error, including mislabeling due to human error.

Can Publicly Available Artificial Intelligence Successfully Identify Current Procedural Terminology Codes for Common Procedures in Neurosurgery?

OBJECTIVE

Coding for neurosurgical procedures is a complex process that is dynamically changing year to year, through the annual introduction and removal of codes and modifiers. The authors hoped to elucidate if publicly available artificial intelligence (AI) could offer solutions for neurosurgeons with regard to coding.

METHODS

Multiple publicly available AI platforms were asked to provide Current Procedural Terminology (CPT) codes and Revenue Value Units (RVU) values for common neurosurgical procedures of the brain and spine with a given indication for the procedure. The responses of platforms were recorded and compared to the currently valid CPT codes used for the procedure and the amount of RVUs that would be gained.

RESULTS

Six platforms and Google were asked for the appropriate CPT codes for 10 endovascular, spinal, and cranial procedures each. The highest performing platforms were as follows: Perplexity.AI identified 70% of endovascular, BingAI identified 55% of spinal, and ChatGPT 4.0 with Bing identified 75% of cranial CPT codes. With regard to RVUs, the top performer gained 78% of endovascular, 42% of spinal, and 70% of cranial possible RVUs. With regard to accuracy, AI platforms on average outperformed Google (45% vs. 25%, P = 0.04236).

CONCLUSIONS

The ability of publicly available AIs to successfully code for neurosurgical procedures holds great promise in the future. Future development of AI should focus on improving accuracy with regard to CPT codes and providing supporting documentation for its decisions. Improvement on the existing capabilities of AI platforms can allow for increased operational efficiency and cost savings for practices.

Development and multicentre validation of the FLEX score: personalised preoperative surgical risk prediction using attention-based ICD-10 and Current Procedural Terminology set embeddings

BACKGROUND

Preoperative knowledge of surgical risks can improve perioperative care and patient outcomes. However, assessments requiring clinician examination of patients or manual chart review can be too burdensome for routine use.

METHODS

We conducted a multicentre retrospective study of 243 479 adult noncardiac surgical patients at four hospitals within the Mass General Brigham (MGB) system in the USA. We developed a machine learning method using routinely collected coding and patient characteristics data from the electronic health record which predicts 30-day mortality, 30-day readmission, discharge to long-term care, and hospital length of stay.

RESULTS

Our method, the Flexible Surgical Set Embedding (FLEX) score, achieved state-of-the-art performance to identify comorbidities that significantly contribute to the risk of each adverse outcome. The contributions of comorbidities are weighted based on patient-specific context, yielding personalised risk predictions. Understanding the significant drivers of risk of adverse outcomes for each patient can inform clinicians of potential targets for intervention.

CONCLUSIONS

FLEX utilises information from a wider range of medical diagnostic and procedural codes than previously possible and can adapt to different coding practices to accurately predict adverse postoperative outcomes.

A Cross-Sectional Study

BACKGROUND

In January 2023, significant changes were implemented to ventral hernia repair Current Procedural Terminology codes, with new codes replacing previous codes. The new codes were assigned a 0-day global period. The impact of these changes on clinical productivity remains unclear. Our objective was to forecast the impact of Current Procedural Terminology changes on ventral hernia-related work relative value units using historical data.

METHODS

Ventral hernia repairs performed between March 2021 and December 2022 on adults by a single surgeon with available 90-day follow-up were retrospectively retrieved from the Abdominal Core Health Quality Collaborative. Demographic, hernia, and operative and postoperative data were collected. The ventral hernia repairs were coded twice using the previous and new Current Procedural Terminology codes, and work relative value units were calculated using both systems. The median work relative value units per case were compared using the Wilcoxon signed-rank test.

RESULTS

A total of 143 ventral hernia repairs were included. The median age was 59 years, and 50% of patients were male. Median hernia width and length were 3.5 and 5.0 cm, respectively. The most common ventral hernia types were incisional 57% and umbilical 33%. Twenty percent of hernias were recurrent, and 99% were elective repairs. 49% of the procedures were open, 30% robotic, and 21% laparoscopic. Component separation was performed in 16%. The median length of stay was 0.0, and the median number of 90-day outpatient postoperative visits was 1.0. The new Current Procedural Terminology coding system was associated with a higher median 90-day work relative value units per case (14.1) than the previous system (13.8) (P = .002). Subset analysis identified statistically higher median 90-day work relative value units per case using the new versus previous Current Procedural Terminology codes for hernias with the largest defect dimension >10 cm (23.3 vs 18.8), umbilical/epigastric/Spigelian hernias (9.2 vs 7.1), recurrent hernias (20.1 vs 17.3) and open ventral hernia repairs (9.8 vs 7.1), all P < .05. Median 90-day work relative value units per case were statistically lower using the new versus previous codes for non-recurrent (11.6 vs 13.8) and incarcerated/strangulated (14.8 vs 14.9) hernias, all P < .05. In the new coding system, postoperative care within 90-days contributed to a median of 1.3 work relative value units per case (9% of total 90-day work relative value units).

CONCLUSION

We forecast that in our practice, the 2023 ventral hernia repair Current Procedural Terminology changes will result in a modest impact on clinical productivity. The impact of these changes on a particular practice depends on surgical practice patterns and ventral hernia case mix.

GRU-D-Weibull: A novel real-time individualized endpoint prediction

BACKGROUND

In the era of healthcare digital transformation, using electronic health record (EHR) data to generate various endpoint estimates for active monitoring is highly desirable in chronic disease management. However, traditional predictive modeling strategies leveraging well-curated data sets can have limited real-world implementation potential due to various data quality issues in EHR data.

METHODS

We propose a novel predictive modeling approach, GRU-D-Weibull, which models Weibull distribution leveraging gated recurrent units with decay (GRU-D), for real-time individualized endpoint prediction and population level risk management using EHR data.

EXPERIMENTS

We systematically evaluated the performance and showcased the real-world implementability of the proposed approach through individual level endpoint prediction using a cohort of patients with chronic kidney disease stage 4 (CKD4). A total of 536 features including ICD/CPT codes, medications, lab tests, vital measurements, and demographics were retrieved for 6879 CKD4 patients. The performance metrics including C-index, L1-loss, Parkes' error, and predicted survival probability at time of event were compared between GRU-D-Weibull and other alternative approaches including accelerated failure time model (AFT), XGBoost based AFT (XGB(AFT)), random survival forest (RSF), and Nnet-survival. Both in-process and post-process calibrations were experimented on GRU-D-Weibull generated survival probabilities.

RESULTS

GRU-D-Weibull demonstrated C-index of ~0.7 at index date, which increased to ~0.77 at 4.3 years of follow-up, comparable to that of RSF. GRU-D-Weibull achieved absolute L1-loss of ~1.1 years (sd≈0.95) at CKD4 index date, and a minimum of ~0.45 year (sd≈0.3) at 4 years of follow-up, comparing to second-ranked RSF of ~1.4 years (sd≈1.1) at index date and ~0.64 years (sd≈0.26) at 4 years. Both significantly outperform competing approaches. GRU-D-Weibull constrained predicted survival probability at time of event to smaller and more fixed range than competing models throughout follow-up. Significant correlations were observed between prediction error and missing proportions of all major categories of input features at index date (Corr ~0.1 to ~0.3), which faded away within 1 year after index date as more data became available. Through post training recalibration, we achieved a close alignment between the predicted and observed survival probabilities across multiple prediction horizons at different time points during follow-up.

CONCLUSION

GRU-D-Weibull shows advantages over competing methods in handling missingness commonly encountered in EHR data and providing both probability and point estimates for diverse prediction horizons during follow-up. The experiment highlights the potential of GRU-D-Weibull as a suitable candidate for individualized endpoint risk management, utilizing real-time clinical data to generate various endpoint estimates for monitoring. Additional research is warranted to evaluate the influence of different data quality aspects on prediction performance. Furthermore, collaboration with clinicians is essential to explore the integration of this approach into clinical workflows and evaluate its effects on decision-making processes and patient outcomes.

Controversies in CPT® coding in the neonatal intensive care unit: - critical vs. intensive care

Professional reimbursement to neonatal providers is based on the level of Current Procedural Terminology (CPT®) coding in the NICU, newborn nursery and other areas where neonatal care is provided. Four levels of evaluation and management (E&M) care-critical, intensive, routine-hospital care or normal newborn care can be provided to neonates. The work relative value units (wRVUs) associated with these four levels of care vary widely. This manuscript provides a brief review of basic features associated with each of these four levels with a specific perspective on differences between critical and intensive care codes. Coding and billing are constantly evolving fields with significant variation in interpretation and readers are encouraged to review the current publications on CPT® coding and make an informed decision on the best codes to be used for their patients.

Relative billing complexity of in-person versus telehealth outpatient encounters

RATIONALE

Video visits became more widely available during the coronavirus disease (COVID-19) pandemic. However, the ongoing role and value of video visits in care delivery and how these may have changed over time are not well understood.

AIMS AND OBJECTIVES

Compare the relative complexity of in-person versus video visits during the COVID-19 pandemic and describe the complexity of video visits over time.

METHODS

We used billing data for in-person and video revisits from non-behavioural health specialities with the most video visit utilisation (≥50th percentile) at a large, urban, public healthcare system from 1 January 2021 to 31 March 2022. We used current procedural terminology (CPT) codes as a proxy for information gathering and decision-making complexity and time spent on an encounter. We compared the distribution of CPT codes 99211-99215 between in-person and video visits using Fisher's exact tests. We used Spearman correlation to test for trends between proportions of CPT codes over time for video visits.

RESULTS

Ten specialities (adult primary care, paediatrics, adult dermatology, bariatric surgery, paediatric endocrinology, obstetrics and gynaecologist, adult haematology/oncology, paediatric allergy/immunology, paediatric gastroenterology, and paediatric pulmonology) met inclusion criteria. For each speciality, proportions of each CPT code for in-person visits and for video visits varied significantly, and patterns of variation differed by speciality. For example, in adult primary care, video visits had smaller proportions of moderate/high complexity visits (99214 and 99215) and greater proportions of lower complexity visits (99211-99213) compared with in-person visits (p < 0.001), but in paediatric endocrinology, the opposite was seen (p < 0.001). Trends in CPT codes over time for video visits in each speciality were also mixed.

CONCLUSION

In-person and video visits had differing proportions of complexity codes (typically skewing towards lower complexity for video visits). The complexity of video visits changed over time in many specialities. Observed patterns for both phenomena varied by speciality.

Variability in Medicaid Reimbursement in Hand Surgery May Lead to Inequality in Access to Patient Care

BACKGROUND

Medicare (MCR) and Medicaid (MCD) remain the dominant providers of government-funded health insurance in the United States. The purpose of this study was to evaluate the variability between MCR and MCD reimbursements for common hand and wrist surgical procedures. We hypothesized that MCD reimbursement rates would have substantial variation between states, whereas MCR rates would remain relatively constant.

METHODS

Using the Medicare Physician Fee Schedule Database, the 2019 reimbursements for 7 common hand and wrist procedures were recorded via the respective Current Procedural Terminology codes. The MCD reimbursement rates were then obtained from each state's physician fee schedule database. Comparisons of reimbursement for these procedures were then calculated between states and between MCD and MCR while adjusting for cost of living using the Medicare Wage Index. Finally, the coefficients of variation were computed to compare the extent of variability between the insurance types.

RESULTS

Across all procedures, reimbursement rates for MCD ranged from 30.6% to 240% of the average MCR reimbursement, with the mean reimbursement for MCD valued at 78.3% of MCR. Endoscopic carpal tunnel release (CTR) is valued similarly by MCD compared with open CTR with an average of 77.7% and 78.2% reimbursement of MCR, respectively. The coefficients of variation for MCD reimbursements ranged from 0.25 to 0.45, whereas the value was 0.06 for all MCR procedures.

CONCLUSIONS

These findings demonstrate a wide variation in MCD payments between states. When compared with MCR, the lower average state MCD reimbursement questions the sustainability for hand surgeons to accept these patients in practice.

Nurses' critical role in CPT code valuation

ABSTRACT

Relative value units (RVUs) are a measurement of practice efficiency and patient complexity. RVUs are reviewed by the Centers for Medicare and Medicaid Services through the Resource-Based Relative-Value Scale Update Committee, which determines recommendations regarding the Current Procedural Terminology code valuations for the Medicare Physician Fee Schedule. This article discusses the importance of nurses' participation in the accurate valuation of their work and in the process of developing and revising RVUs.

Are work relative value units correlated with operative duration of common surgical procedures?

OBJECTIVES

Work relative value units (wRVUs) quantify physician workload. In theory, higher wRVU assignments for procedures recognize an increase in complexity and time required to complete the procedure. The fairness of wRVU assignment is debated across specialties, with some surgeons arguing that reimbursement may be unfairly low for longer, more complex cases. For this reason, we sought to assess the correlation of wRVUs with operative time in commonly performed surgeries.

STUDY DESIGN

We analyzed the National Surgical Quality Improvement Program database, selecting the 15 most performed surgical procedures across specialties in a 90-day global period, using Current Procedural Terminology codes.

METHODS

Calculation and comparison of mean operative time and mean wRVUs were performed for each of the 15 procedures. Cases with missing values for wRVUs or operative time and cases with an operative time of less than 15 minutes were excluded. The Spearman correlation coefficient was calculated to evaluate the strength of correlation between operative duration and wRVUs.

RESULTS

A total of 1,994,394 patients met criteria for analysis. The lowest mean wRVU was 7.78 (95% CI, 7.77-7.78) for inguinal hernia repair; the highest was 43.50 (95% CI, 43.37-43.60) for pancreatectomy. The shortest mean operative time was 51.0 (95% CI, 50.8-51.1) minutes for appendectomy; the longest was for pancreatectomy at 324.6 (95% CI, 323.2-326.0) minutes. The Spearman correlation coefficient was 0.81.

CONCLUSIONS

In our analysis, we found a strong correlation between operative duration and wRVU assignment. Thus, the reimbursement of physicians depending on wRVUs is fair for the most commonly performed surgical procedures across specialties.

Discrepancies in rib fracture severity between radiologist and surgeon: A retrospective review

BACKGROUND

Chest computed tomography (CT) scans are important for the management of rib fracture patients, especially when determining indications for surgical stabilization of rib fractures (SSRFs). Chest CTs describe the number, patterns, and severity of rib fracture displacement, driving patient management and SSRF indications. Literature is scarce comparing radiologist versus surgeon rib fracture description. We hypothesize there is significant discrepancy between how radiologists and surgeons describe rib fractures.

METHODS

This was an institutional review board-approved, retrospective study conducted at a Level I academic center from December 2016 to December 2017. Adult patients (≥18 years of age) suffering rib fractures with a CT chest where included. Basic demographics were obtained. Outcomes included the difference between radiologist versus surgeon description of rib fractures and differences in the number of fractures identified. Rib fracture description was based on current literature: 1, nondisplaced; 2, minimally displaced (<50% rib width); 3, severely displaced (≥50% rib width); 4, bicortically displaced; 5, other. Descriptive analysis was used for demographics and paired t test for statistical analysis. Significance was set at p = 0.05.

RESULTS

Four hundred and ten patients and 2,337 rib fractures were analyzed. Average age was 55.6(±20.6); 70.5% were male; median Injury Severity Score was 16 (interquartile range, 9-22) and chest Abbreviated Injury Scale score was 3 (interquartile range, 3-3). For all descriptive categories, radiologists consistently underappreciated the severity of rib fracture displacement compared with surgeon assessment and severity of displacement was not mentioned for 35% of rib fractures. The mean score provided by the radiologist was 1.58 (±0.63) versus 1.78 (±0.51) by the surgeon (p < 0.001). Radiologists missed 138 (5.9%) rib fractures on initial CT. The sensitivity of the radiologist to identify a severely displaced rib fracture was 54.9% with specificity of 79.9%.

CONCLUSION

Discrepancy exists between radiologist and surgeon regarding rib fracture description on chest CT as radiologists routinely underappreciate fracture severity. Surgeons need to evaluate CT scans themselves to appropriately decide management strategies and SSRF indications.

LEVEL OF EVIDENCE

Prognostic/Diagnostic Test, level III.

The Transformation of Documenting and Coding: Evaluation and Management Codes for Outpatient Neurology Services

ABSTRACT

This article discusses the optimal ways to document and code for outpatient evaluation and management (E/M) codes. Since the changes for Current Procedural Terminology (CPT) codes 99202-99215 were finalized for 2021, they have been modified by the Centers for Medicare & Medicaid Services (CMS) in their Medicare Physician Fee Schedule and by technical corrections issued on March 9, 2021. The 21st Century Cures Act mandated that patients can access their notes and test results immediately. These developments have transformed medical documentation and coding for outpatient E/M services. One year in, the authors have a better understanding of the subtleties of documenting and accurately determining levels of service for outpatient encounters using these new rules and regulations, and they share key insights gained by experience with the new system.

A tree based approach for multi-class classification of surgical procedures using structured and unstructured data

BACKGROUND

In surgical department, CPT code assignment has been a complicated manual human effort, that entails significant related knowledge and experience. While there are several studies using CPTs to make predictions in surgical services, literature on predicting CPTs in surgical and other services using text features is very sparse. This study improves the prediction of CPTs by the means of informative features and a novel re-prioritization algorithm.

METHODS

The input data used in this study is composed of both structured and unstructured data. The ground truth labels (CPTs) are obtained from medical coding databases using relative value units which indicates the major operational procedures in each surgery case. In the modeling process, we first utilize Random Forest multi-class classification model to predict the CPT codes. Second, we extract the key information such as label probabilities, feature importance measures, and medical term frequency. Then, the indicated factors are used in a novel algorithm to rearrange the alternative CPT codes in the list of potential candidates based on the calculated weights.

RESULTS

To evaluate the performance of both phases, prediction and complementary improvement, we report the accuracy scores of multi-class CPT prediction tasks for datasets of 5 key surgery case specialities. The Random Forest model performs the classification task with 74-76% when predicting the primary CPT (accuracy@1) versus the CPT set (accuracy@2) with respect to two filtering conditions on CPT codes. The complementary algorithm improves the results from initial step by 8% on average. Furthermore, the incorporated text features enhanced the quality of the output by 20-35%. The model outperforms the state-of-the-art neural network model with respect to accuracy, precision and recall.

CONCLUSIONS

We have established a robust framework based on a decision tree predictive model. We predict the surgical codes more accurately and robust compared to the state-of-the-art deep neural structures which can help immensely in both surgery billing and scheduling purposes in such units.

Correlation of Supervised Independence and Performance with Procedure Difficulty amongst Surgical Residents Stratified by Post Graduate Year

PURPOSE

This study investigates the role of procedure difficulty on attending ratings of supervised levels of independence and procedural performance amongst general surgery residents, while accounting for case complexity.

METHODS

Attending ratings for residents were obtained from System for Improving and Measuring Procedural Learning (SIMPL) database. Current procedural terminology (CPT) codes were used to match procedures to a corresponding work relative value unit (wRVU) as a surrogate for procedure difficulty. Three categories of wRVU (<13.07, 13.07-22, >22) were identified using recursive partitioning. Procedures were also divided into 'Core' or 'Advanced' as defined by the American Board of Surgery Surgical Council on Resident Education (SCORE). Temporal advancement in resident skill was accounted for through academic quarterly analysis. A generalized estimating equations (GEE) approach was used to form separate multivariable logistic regression models for meaningful autonomy (MA) and satisfactory performance (SP) adjusted for potential clustering by program, subject, and rater. Models were further adjusted for core/advanced procedures, attending rated complexity, and academic quarter.

RESULTS

A total of 33,281 ratings were analyzed. Overall, 51.6% were rated as MA and 44.4% as SP. For core procedures, surgical residents rated as MA (53.5%) and SP (45.7%), which was twice as high as those for advance procedures (MA-29.2%, SP-29.0%). MA and SP both decreased with increasing wRVU (Figure 2 &3). Using a wRVU<13.07 as a reference, the adjusted odds ratios of MA and SP were significantly lower with increasing procedure difficulty, 0.44 for wRVU 13.07-22.0 and 0.24 for wRVU >22.00 (Table 3). Post graduate year (PGY) 5 residents in the final quarter of training obtain MA in 95.5% and SP 92.9% for core procedures with wRVU <13.07 (Table 4).

CONCLUSION

Increasing procedural difficulty is independently associated with decreases in meaningful autonomy and satisfactory performance. As residents approach graduation the level of meaningful autonomy and satisfactory performance both reach high levels for common core procedures but decrease as procedural difficulty increases.

Simplifying Measurement of Adenoma Detection Rates for Colonoscopy

BACKGROUND

Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly.

AIMS

Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR.

METHODS

We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites.

RESULTS

Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05).

CONCLUSIONS

Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.

Hypoglossal Nerve Stimulator: A Novel Treatment Approach for OSA - Overview of Treatment, Including Diagnostic and Patient Criteria and Procedural Terminology Codes

Unilateral stimulation of the hypoglossal nerve may result in clinically valuable patency of the upper airway in well-selected patients for treatment of OSA. The Food and Drug Administration has established stringent criteria for the placement of this medical device. The treatment is a consideration among patients who have been nonadherent or intolerant of positive airway pressure therapy, with moderate to severe OSA, and a BMI of ≤ 32 kg/m². Some of the insurance providers have lowered BMI guidelines to allow implantation in patients with a BMI of < 35 kg/m². Further, a clinical assessment with sleep endoscopy is available to define proper anatomic features and to determine, based on the results, if the patients are appropriate surgical candidates. Current Procedural Terminology codes that are specific to the placement as well as removal or replacement of the device, or both, are discussed, as well as sleep medicine-related evaluation and management.

Effectiveness of the Recombinant Zoster Vaccine for Herpes Zoster Ophthalmicus in the United States

PURPOSE

To examine the effectiveness of the recombinant zoster vaccine (RZV) for preventing herpes zoster ophthalmicus (HZO) in the general United States population.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

Individuals enrolled in the OptumLabs Data Warehouse (OLDW; OptumLabs, Cambridge, MA) who were age eligible for herpes zoster (HZ) vaccination (≥50 years of age) from 2018 through 2019. The OLDW is a longitudinal, de-identified administrative claims and electronic health record database of patients in the United States with commercial insurance, Medicare Part D, or Medicare Advantage METHODS: Patients were required to have 365 days or more of continuous enrollment to be eligible. Those with a diagnosis code of HZ or an immunocompromising condition within 1 year before study inclusion were excluded. Vaccination with the RZV was ascertained by Current Procedural Terminology codes, and HZO was ascertained by International Classification of Diseases, Tenth Revision, codes. Cox proportional hazards regression models were used to estimate the hazard ratio of HZO associated with RZV, and inverse-probability weighting was used to control for confounding. Vaccine effectiveness was calculated from hazard ratios.

MAIN OUTCOME MEASURES

Incidence of HZO in vaccinated versus unvaccinated person-times and vaccine effectiveness were assessed.

RESULTS

From January 1, 2018, through December 31, 2019, a total of 4 842 579 individuals were included in this study. One hundred seventy-seven thousand two hundred eighty-nine (3.7%) received 2 valid doses of RZV. The incidence rate of HZO was 25.5 cases (95% confidence interval [CI], 17.4-35.8 cases) per 100 000 person-years in the vaccinated group compared with 76.7 cases (95% CI, 74.7-78.7 cases) in the unvaccinated group. The overall adjusted effectiveness of RZV against HZO was 89.1% (95% CI, 82.9%-93.0%).

CONCLUSIONS

The effectiveness of RZV against HZO in individuals 50 years of age and older is high in a clinical setting. However, the low vaccination rate in this study highlights the public health need to increase HZV use. Ophthalmologists can play an important role in recommending vaccination to eligible patients.

SynTEG: a framework for temporal structured electronic health data simulation

OBJECTIVE

Simulating electronic health record data offers an opportunity to resolve the tension between data sharing and patient privacy. Recent techniques based on generative adversarial networks have shown promise but neglect the temporal aspect of healthcare. We introduce a generative framework for simulating the trajectory of patients' diagnoses and measures to evaluate utility and privacy.

MATERIALS AND METHODS

The framework simulates date-stamped diagnosis sequences based on a 2-stage process that 1) sequentially extracts temporal patterns from clinical visits and 2) generates synthetic data conditioned on the learned patterns. We designed 3 utility measures to characterize the extent to which the framework maintains feature correlations and temporal patterns in clinical events. We evaluated the framework with billing codes, represented as phenome-wide association study codes (phecodes), from over 500 000 Vanderbilt University Medical Center electronic health records. We further assessed the privacy risks based on membership inference and attribute disclosure attacks.

RESULTS

The simulated temporal sequences exhibited similar characteristics to real sequences on the utility measures. Notably, diagnosis prediction models based on real versus synthetic temporal data exhibited an average relative difference in area under the ROC curve of 1.6% with standard deviation of 3.8% for 1276 phecodes. Additionally, the relative difference in the mean occurrence age and time between visits were 4.9% and 4.2%, respectively. The privacy risks in synthetic data, with respect to the membership and attribute inference were negligible.

CONCLUSION

This investigation indicates that temporal diagnosis code sequences can be simulated in a manner that provides utility and respects privacy.

Hospital discharge data is not accurate enough to monitor the incidence of postpartum hemorrhage

INTRODUCTION

Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality worldwide. Therefore, cumulative incidence of postpartum hemorrhage and severe postpartum hemorrhage are commonly monitored within and compared across maternity hospitals or countries for obstetrical safety improvement. These indicators are usually based on hospital discharge data though their accuracy is seldom assessed. We aimed to measure postpartum hemorrhage and severe postpartum hemorrhage using electronic health records and hospital discharge data separately and compare the detection accuracy of these methods to manual chart review, and to examine the temporal trends in cumulative incidence of these potentially avoidable adverse outcomes.

MATERIALS AND METHODS

We analyzed routinely collected data of 7904 singleton deliveries from a large Swiss university hospital for a three year period (2014-2016). We identified postpartum hemorrhage and severe postpartum hemorrhage in electronic health records by text mining discharge letters and operative reports and calculating drop in hemoglobin from laboratory tests. Diagnostic and procedure codes were used to identify cases in hospital discharge data. A sample of 334 charts was reviewed manually to provide a reference-standard and evaluate the accuracy of the other detection methods.

RESULTS

Sensitivities of detection algorithms based on electronic health records and hospital discharge data were 95.2% (95% CI: 92.6% 97.8%) and 38.2% (33.3% to 43.0%), respectively for postpartum hemorrhage, and 87.5% (85.2% to 89.8%) and 36.2% (26.3% to 46.1%) for severe postpartum hemorrhage. Postpartum hemorrhage cumulative incidence based on electronic health records decreased from 15.6% (13.1% to 18.2%) to 8.5% (6.7% to 10.5%) from the beginning of 2014 to the end of 2016, with an average of 12.5% (11.8% to 13.3%). The cumulative incidence of severe postpartum hemorrhage remained at approximately 4% (3.5% to 4.4%). Hospital discharge data-based algorithms provided significantly underestimated incidences.

CONCLUSIONS

Hospital discharge data is not accurate enough to assess the incidence of postpartum hemorrhage at hospital or national level. Instead, automated algorithms based on structured and textual data from electronic health records should be considered, as they provide accurate and timely estimates for monitoring and improvement in obstetrical safety. Furthermore, they have the potential to better code for postpartum hemorrhage thus improving hospital reimbursement.

Vascular Surgeons Are Not Adequately Valued by Traditional Productivity Metrics

BACKGROUND

Reimbursements for professional services performed by clinicians are under constant scrutiny. The value of a vascular surgeon's services as measured by work relative value units (wRVUs) and professional reimbursement has decreased for some of the most common procedures performed. Hospital reimbursements, however, often remain stable or increases. We sought to evaluate fistulagrams as a case study and hypothesized that while wRVUs and professional reimbursements decrease, hospital reimbursements for these services increased over the same time period.

METHODS

Medicare 5% claims data were reviewed to identify all fistulagrams with or without angioplasty or stenting performed between 2015 and 2018 using current procedural terminology codes. Reimbursements were classified into 3 categories: medical center (reimbursements made to a hospital for a fistulagram performed as an outpatient procedure), professional (reimbursement for fistulagrams based on compensation for procedures: work RVUs, practice expense RVU, malpractice expense RVU), and office-based laboratory (OBL, reimbursement for fistulagrams performed in an OBL setting). Medicare's Physician Fee Schedule was used to calculate wRVU and professional reimbursement. Medicare's Hospital Outpatient Prospective Payment System-Ambulatory Payment Classification was used to calculate hospital outpatient reimbursement.

RESULTS

From 2015 to 2018, we identified 1,326,993 fistulagrams. During this study period, vascular surgeons experienced a 25% increase in market share for diagnostic fistulagrams. Compared with 2015, total professional reimbursements from 2017 to 2018 for all fistulagram procedures decreased by 41% (-$10.3 million) while OBL reimbursement decreased 29% (-$42.5 million) and wRVU decreased 36%. During the same period, medical center reimbursement increased by 6.6% (+$14.1 million).

CONCLUSIONS

Vascular surgeons' contribution to a hospital may not be accurately reflected through traditional RVU metrics alone. Vascular surgeons performed an increasing volume of fistulagram procedures while experiencing marked reductions in wRVU and reimbursement. Medical centers, on the other hand, experienced an overall increase in reimbursement during the same time period. This study highlights that professional reimbursements, taken in isolation and without consideration of medical center reimbursement, undervalues the services and contributions provided by vascular surgeons.

Reimbursement for Hip Fractures: The Impact of Varied Current Procedural Terminology Coding Using Relative Value Units

BACKGROUND

Many orthopedic practices routinely code hip fracture hemiarthroplasty as Current Procedural Terminology (CPT) 27125 even though 27236 is the correct CPT code. Our objective is to determine the financial impact this simple mistake has on surgeon reimbursement.

METHODS

Our data comprised cases assigned International Classification of Diseases, Tenth Revision code S72.001A through S72.035A and CPT code 27125 or 27236 within the American College of Surgeons National Surgical Quality Improvement Program 2016-2017 database. Relative value units (RVUs) per CPT code and the Centers for Medicare and Medicaid Services reported that RVU conversion factor of $36.0896 per 1 RVU was used to calculate reimbursement per case. The dollar difference and percent difference per case was then calculated between cases assigned CPT code 27125 and those assigned 27236.

RESULTS

Our total sample consisted of 12,287 National Surgical Quality Improvement Program cases. Of those, 4185 (34%) were cases of a hip fracture treated with hemiarthroplasty that were incorrectly coded as CPT code 27125. That error in coding results in a decrease in reimbursement of $35.01 per case, a 5.51% difference.

CONCLUSION

Since the current healthcare reimbursement model relies solely on CPT codes to determine RVUs, it is imperative that orthopedic surgeons understand the financial impact of incorrect coding. Although correct coding of hemiarthroplasty procedures for hip fractures is an easy task to fix in the future, we hope that through this study a greater emphasis is placed on coding in orthopedic surgery.

Evaluation and Management Codes for Outpatient Neurology Services in 2021: Changes to 99202-99215

Medical services can be conceptualized as falling into two categories: procedures and cognitive care. A procedure is defined as a surgical, medical, or diagnostic test performed on a patient, such as an x-ray, wound suture, surgery, or physical therapy treatment. Cognitive care, also known as Evaluation and Management (E/M) services, involves performing a medical history along with a physical examination and possibly ordering or reviewing diagnostic tests before formulating a medical opinion and initiating a care plan. The uniform language and categorization of all medical services is contained in the Current Procedural Terminology (CPT) manual by the American Medical Association, which precisely describes all medical services using non-overlapping definitions and descriptions. The codes defined by CPT are the most commonly accepted set of codes used to file medical claims. In 2000, the US Department of Health and Human Services designated CPT to be the national reporting standard used in conjunction with the Health Insurance Portability and Accountability Act (HIPAA). CPT codes used today for E/M services were established in 1995 and define the components of history, examination, and medical decision making necessary to determine the level of each cognitive care service as delivered by a physician or other qualified health care professionals (eg, advanced practice providers). E/M rules were modified in 1997 and allowed some specialty services, such as neurology, to substitute a single system examination for a general, multisystem physical examination. Although new E/M codes were added over the years, the code descriptions and documentation guidelines for E/M services for outpatient and inpatient care remained essentially unchanged from 1997 through 2020. Most of the work performed by neurologists is E/M services, and the rules for coding outpatient care will change dramatically on January 1, 2021. This article discusses the rationale for these coding changes and explains how they are to be applied in the clinical setting.

Validation of current procedural terminology codes for surgical stabilization of rib fractures

INTRODUCTION

Current procedural terminology (CPT) codes for surgical stabilization of rib fractures (SSRF) are based solely on the number of ribs fixed, tricotomized at 1-3, 4-6, and ≥ 7. Our objective was to validate CPT codes against operative time at our institution, as well as further stratify complexity by rib fracture location and surgical approach. The purpose of this study is to validate the current CPT coding schema for SSRF, and to identify potential modifiers that are associated with increased case complexity. We hypothesized that operative time is associated with CPT code, number of fractures repaired, exposure technique, and fracture location.

METHODS

Retrospective review of SSRF cases from October 2010 to March 2020. The primary outcome was the length of the operation (minutes). Predictor variables were CPT code, number of fractures repaired (grouped similarly to CPT codes), fractures repaired:ribs repaired ratio > 1, fracture location (sub-scapular vs. other), and positioning/exposure (supine, lateral, prone, and multiple). Kaplan-Meier time-to-event analyses were used to assess relationship with operative time.

RESULTS

188 patients underwent repair of 904 fractures. Operative time was significantly associated with both number of ribs repaired and number of fractures repaired (p<0.01). Although operative time varied significantly by CPT group (p<0.01), there was no significant difference between the 4-6 rib and the ≥ 7 rib groups (p = 0.33). By contrast, each group was significantly different from the others when organized by number of fractures repaired (p = 0.04). Operative time was significantly longer when the fractures repaired:ribs repaired ratio was > 1 (p<0.01), even after stratifying by number of ribs repaired. Both multiple positions/exposures (p<0.01), and repair of ≥ 1 sub-scapular fracture (p<0.01) were significantly associated with operative time.

CONCLUSION

Number of fractures repaired provided a more accurate estimation of operative time as compared to number of ribs repaired. Based on these data, we recommend altering the CPT schema for SSRF to involve number of fractures repaired, with modifiers for both multiple positions/exposures and repair of sub-scapular fractures.

Coding Education in Residency and in Practice Improves Accuracy of Coding in Orthopedic Surgery

The goal of training in orthopedic residency is to produce surgeons who are proficient in all aspects of the practice of orthopedic surgery; however, most residents receive either inadequate or no training in medical coding. The purpose of this study was to determine how well orthopedic residents code when compared with practicing surgeons and to identify whether coding education improves accuracy in medical coding. A mock coding survey was developed using commonly encountered orthopedic clinical scenarios. The survey was distributed to orthopedic trainees post-graduate years (PGY) 1 to 6 at 2 training programs and to attending surgeons. Results were analyzed in 3 groups: junior residents (PGY 1-3), senior residents (PGY 4-6), and attending surgeons. Overall and subcategory scores of (1) type of visit, (2) modifiers, (3) Evaluation and Management (E/M), and (4) Current Procedural Terminology code identification were recorded. Participants were also asked if they had ever received various forms of coding education. Sixty-seven total participants were enrolled, including 28 junior residents, 24 senior residents, and 15 attendings. Practicing surgeons performed significantly better than both senior (P<.027) and junior (P<.001) residents in all categories, with a mean overall correct response rate of 72.8%, 51.0%, and 47.4%, respectively. Any form of coding education was associated with a significantly improved overall score for residents (P=.013) and a nonsignificant increase for attending surgeons (P=.390). This study demonstrates that residents performed poorly when identifying proper billing codes for common procedures and encounters in orthopedic surgery. Further, those participants who received coding education did better than those who did not. [Orthopedics. 2020;43(6):380-383.].

Trends of utilization and physician payments for vertebroplasty and kyphoplasty procedures by physician specialty and practice setting: 2010 to 2018

BACKGROUND CONTEXT

In 2010, the American Academy of Orthopedic Surgeons published guidelines strongly recommending against the use of vertebroplasty following the publication of randomized control trials that failed to show significant improvement in pain. Vertebroplasty has remained controversial since those findings.

PURPOSE

To study and provide an update on utilization of vertebroplasty and kyphoplasty procedures among Medicare beneficiaries by physician specialty and practice setting following publication of recommendations against vertebroplasty in 2010.

STUDY DESIGN/SETTING

This study uses Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 to 2018 to determine trends in volume and reimbursement by physician specialty and practice setting.

PATIENT SAMPLE

All vertebral augmentation procedures with a physician reimbursement claims approved by Medicare Part B from 2010 to 2018.

OUTCOME MEASURES

This study analyzes trends in volume and physician payment of vertebroplasty and kyphoplasty procedures by physician specialty for the time period 2010 to 2018.

METHODS

Claims from the Medicare Part B PSPSMF for the years 2010 to 2018 were extracted using the Current Procedural Terminology codes for vertebroplasty and kyphoplasty. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty.

RESULTS

Between 2010 and 2018, the total volume of vertebroplasties decreased by 61.2% (29,995 to 11,654), whereas the volume of kyphoplasties increased modestly by 14.4% (59,691 to 68,294). Radiologists performed an increasing share of both procedures over this time period, from 68.5% to 75.1% for vertebroplasties and 28.9% to 37.1% for kyphoplasties. Total payment for vertebroplasties decreased by 74.3% from $14.8 million in 2010 to $3.8 million in 2018; whereas it increased by 235.3% for kyphoplasty procedures from $26.7 million to $89.7 million. This is driven in large part by a 6,833% increase in office based kyphoplasties which bill at the higher nonfacility rate that incorporates overhead, staff, and equipment.

CONCLUSIONS

Previous studies have demonstrated mixed evidence for benefits of vertebroplasty procedures and decreasing volumes over time. Data show continued downtrend in vertebroplasty and increased utilization of kyphoplasty among Medicare beneficiaries. In addition, the growing number of kyphoplasties correlated with a sharp rise in volume and increased reimbursement for office-based procedures. Radiologists have been performing an increasing share of both procedures.

Current Procedural Terminology Codes for Medication Therapy Management in Administrative Data

BACKGROUND

Three pharmacist-specific Current Procedural Terminology (CPT) codes exist to facilitate medication therapy management (MTM) reimbursement (codes 99605, 99606, and 99607). However, no studies have used CPT codes in administrative claims databases to identify subjects who have received MTM services.

OBJECTIVE

To assess the prevalence of MTM services provided, using CPT codes identified in an administrative dataset.

METHODS

A retrospective cohort study was conducted using a subset of Medicare Part D individuals from the IBM MarketScan Medicare Supplemental Research Databases (2009-2015). Researchers identified beneficiaries who received MTM services using CPT codes 99605, 99606, and 99607.

RESULTS

Of the 16,483,709 individuals in the dataset, only 3,291 had CPT codes indicating that they received MTM services, representing an overall prevalence of 0.020%.

CONCLUSIONS

The use of CPT codes as an indicator of MTM service provision resulted in far lower MTM utilization rates than in published literature. Reliance on CPT codes to identify MTM services in administrative claims is not recommended, given that it limited the researchers' ability to properly identify patient receipt of such services. More accurate methodologies are warranted for identifying MTM use and its effects on patient outcomes.

DISCLOSURES

This work was supported by Pharmacy Quality Alliance; Merck Sharp & Dohme, a subsidiary of Merck & Co. (Kenilworth, NJ); and SinfoniaRx. The funding sources had no role in study design, collection, analysis, and interpretation of data, writing the report, or decision to submit the article for publication. Tate, Chinthammit, and Campbell completed this work during their employment at the University of Arizona. Pickering was an employee of Pharmacy Quality Alliance at the time of this study. Black is employed by Merck. Axon reports grants from the Arizona Department of Health Services and the American Association of Colleges of Pharmacy; Campbell reports a grant from the Community Pharmacy Foundation; Chinthammit reports fees from Eli Lilly; Black has received a grant from Merck; Warholak reports grants from the Arizona Department of Health Services and Novartis, all unrelated to this study. Taylor reports grants from Tabula Rasa Op-Co, during the conduct of the study, and from the Arizona Department of Health Services, outside the conduct of this study. This research was accepted as a poster presentation at the International Society for Pharmacoeconomics and Outcomes Research Annual Meeting, May 16-20, 2020, in Orlando, FL, but was not presented due to the COVID-19 pandemic. An abstract was published in Value in Health, 2020;23(Suppl 1):S305.

Classification performance of administrative coding data for detection of invasive fungal infection in paediatric cancer patients

BACKGROUND

Invasive fungal infection (IFI) detection requires application of complex case definitions by trained staff. Administrative coding data (ICD-10-AM) may provide a simplified method for IFI surveillance, but accuracy of case ascertainment in children with cancer is unknown.

OBJECTIVE

To determine the classification performance of ICD-10-AM codes for detecting IFI using a gold-standard dataset (r-TERIFIC) of confirmed IFIs in paediatric cancer patients at a quaternary referral centre (Royal Children's Hospital) in Victoria, Australia from 1st April 2004 to 31st December 2013.

METHODS

ICD-10-AM codes denoting IFI in paediatric patients (<18-years) with haematologic or solid tumour malignancies were extracted from the Victorian Admitted Episodes Dataset and linked to the r-TERIFIC dataset. Sensitivity, positive predictive value (PPV) and the F1 scores of the ICD-10-AM codes were calculated.

RESULTS

Of 1,671 evaluable patients, 113 (6.76%) had confirmed IFI diagnoses according to gold-standard criteria, while 114 (6.82%) cases were identified using the codes. Of the clinical IFI cases, 68 were in receipt of ≥1 ICD-10-AM code(s) for IFI, corresponding to an overall sensitivity, PPV and F1 score of 60%, respectively. Sensitivity was highest for proven IFI (77% [95% CI: 58-90]; F1 = 47%) and invasive candidiasis (83% [95% CI: 61-95]; F1 = 76%) and lowest for other/unspecified IFI (20% [95% CI: 5.05-72%]; F1 = 5.00%). The most frequent misclassification was coding of invasive aspergillosis as invasive candidiasis.

CONCLUSION

ICD-10-AM codes demonstrate moderate sensitivity and PPV to detect IFI in children with cancer. However, specific subsets of proven IFI and invasive candidiasis (codes B37.x) are more accurately coded.

National Trends in Oncologic Diagnostic Imaging

OBJECTIVE

To characterize national trends in oncologic imaging (OI) utilization.

METHODS

This retrospective cross-sectional study used 2004 and 2016 CMS 5% Carrier Claims Research Identifiable Files. Radiologist-performed, primary noninvasive diagnostic imaging examinations were identified from billed Current Procedural Terminology codes; CT, MRI, and PET/CT examinations were categorized as "advanced" imaging. OI examinations were identified from imaging claims' primary International Classification of Diseases-9 and International Classification of Diseases-10 codes. Imaging services were stratified by academic practice status and place of service. State-level correlations of oncologic advanced imaging utilization (examinations per 1,000 beneficiaries) with cancer prevalence and radiologist supply were assessed by Spearman correlation coefficient.

RESULTS

The national Medicare sample included 5,051,095 diagnostic imaging examinations (1,220,224 of them advanced) in 2004 and 5,023,115 diagnostic imaging examinations (1,504,608 of them advanced) in 2016. In 2004 and 2016, OI represented 4.3% and 3.9%, respectively, of all imaging versus 10.8% and 9.5%, respectively, of advanced imaging. The percentage of advanced OI done in academic practices rose from 18.8% in 2004 to 34.1% in 2016, leaving 65.9% outside academia. In 2016, 58.0% of advanced OI was performed in the hospital outpatient setting and 23.9% in the physician office setting. In 2016, state-level oncologic advanced imaging utilization correlated with state-level radiologist supply (r = +0.489, P < .001) but not with state-level cancer prevalence (r = -0.139, P = .329).

DISCUSSION

OI usage varied between practice settings. Although the percentage of advanced OI done in academic settings nearly doubled from 2004 to 2016, the majority remained in nonacademic practices. State-level oncologic advanced imaging utilization correlated with radiologist supply but not cancer prevalence.

Effect of Global Fracture Care Billing on Distal Radius Fractures

Nonoperative distal radius fracture treatment without manipulation can be coded and billed in a global fee or itemized structure. Little is known regarding the association between these coding/billing structures and subsequent clinical care. The MarketScan Research Database (IBM, Armonk, New York) was retrospectively queried for patients with a distal radius fracture diagnosis code from 2003 to 2014. Patients with a Current Procedural Terminology code for surgical treatment or closed treatment with manipulation were excluded. The remaining nonoperatively treated patients were separated based on billing structure. Results were analyzed for provider initiating global fracture care, as well as the likelihood and frequency of follow-up visits related to the injury for each group. A total of 381,561 patients were identified based on inclusion criteria. Global fracture care billing was initiated for 177,153 (46%) patients, whereas itemized billing was performed for 204,408 (54%) patients. Orthopedic surgeons were the most likely provider (69%) to initiate global fracture care after diagnosis of distal radius fracture. Emergency physicians were the second most common specialty (6%). Patients for whom global fracture care was initiated were more likely to not receive any follow-up office visits compared with patients for whom itemized billing was performed (39.2% vs 25.4%). Additionally, patients with global billing had significantly fewer office visits during the 90-day global period (1.3 vs 2.3). This study demonstrates that patients billed via global fracture care have less frequent follow-up and fewer office visits during the 90-day global period than patients billed in itemized fashion. [Orthopedics. 2020;43(5);e471-e475.].

Basic and Advanced Pleural Procedures: Coding and Professional Fees Update for Pulmonologists

There is an evolution of pleural procedures that involve broadened clinical indication and expanded scope that include advanced diagnostic, therapeutic, and palliative procedures. Finance and clinical professionals have been challenged to understand the indication and coding complexities that accompany these procedures. This article describes the utility of pleural procedures, the appropriate current procedural terminology coding, and necessary modifiers. Coding pearls that help close the knowledge gap between basic and advanced procedures aim to address coding confusion that is prevalent with pleural procedures and the risk of payment denials, potential underpayment, and documentation audits.

Coding in the World of COVID-19: Non-Face-to-Face Evaluation and Management Care

Almost all medical care in the United States is delivered with the provider and patient in immediate proximity; this model is referred to as face-to-face care. Medical services can be apportioned as procedural care (eg, surgery, radiology, or laboratory testing and others) or cognitive care, also known as Evaluation and Management (E/M) services, in which the provider formulates an assessment and plan after obtaining information from the patient's history, examination, and diagnostic tests.Providing a medical opinion and plan using the telephone as the technology that links the provider and the patient is an example of a non-face-to-face E/M service. Common Procedural Terminology (CPT) codes and the details for how to provide telephone services have been available for decades but have not been reimbursed and therefore were rarely used. In recent years, as new technologies have evolved, there has been slow and steady acceptance that non-face-to-face E/M care can be an adjunct to or replacement for some face-to-face E/M services. These technologies and the descriptors for associated CPT and Healthcare Common Procedure Coding System (HCPCS) codes were introduced over the past few years and have become known by the generic term telehealth. They have been slowly incorporated into medical practice. Most of these services were introduced in the consumer retail market, in which the cost was borne directly by the patient, or as private contract services, in which the cost was borne by the consulting hospital, such as with telestroke services. In both the consumer retail model and private contract model, the care delivered usually did not involve CPT or HCPCS coding. The adoption of telehealth has been slow, in part because of the initial costs and several regulatory constraints, as well as the reluctance of patients, providers, and the insurance industry to change the concept that medical care could only be delivered when the patient and their provider were in physical proximity.After the COVID-19 pandemic reached the United States, the US Department of Health & Human Services issued a public health emergency and declared a Section 1135 Waiver that lifted many of the administrative constraints. With the need for near-absolute social distancing, this perfect storm has resulted in the immediate adoption of telemedicine, at least for the duration of the pandemic, for cognitive care to be delivered using communication technologies that are already in place. This article discusses the most common forms of non-face-to-face E/M care and the proper coding elements necessary to provide these services.

Trends in Orthopedic Surgery Reimbursement From 2000 to 2015

Understanding trends in reimbursement for orthopedic surgery is important, especially considering the changing landscape of health care delivery and payment models. Although other studies have examined these trends using a sampling of common orthopedic procedures compared with non-orthopedic specialties, robust examination across all orthopedic specialties is not available in the current literature. This study aimed to critically analyze the trends in reimbursement in the field of orthopedic surgery. Inflation-adjusted Medicare reimbursement and work relative value units (RVUs) between 2000 and 2016 for more than 200 individual Current Procedural Terminology codes across all major orthopedic subspecialties were analyzed, and inherent value of work RVUs was assessed by dividing reimbursement dollar values by work RVUs annually and tracking the changes. Between 2000 and 2016, reimbursement decreased across all orthopedic subspecialties by an average of 29%, except oncology, which showed a 6% increase. Work RVUs increased by an average of 10%, but the inherent value of work RVUs decreased across all orthopedic subspecialties by an average of 39%. Increased active involvement of orthopedic attending physicians and residents in coding documentation and fee-schedule representation is needed. [Orthopedics. 2020;43(3):187-190.].

Special report: implementing immediate postpartum LARC in Florida

Women are often highly motivated to obtain contraception during the immediate postpartum period. However, not all women receive contraception, particularly long-acting reversible contraceptive methods, during this time. One barrier to immediate postpartum contraception is the cost of placing long-acting reversible contraceptives, because such devices have a large upfront cost and historically could not be charged separately from the global delivery fee. In 2017, Florida Medicaid unbundled the fee for the long-acting reversible contraceptive device and insertion from the Diagnosis Related Group and encouraged Medicaid Managed Care plans to do the same. The Florida Perinatal Quality Collaborative, in recognition of guidance put forth by other states, designed the Access LARC initiative to have 2 phases: the preimplementation phase and the implementation phase. After completing all steps in the preimplementation phase, 1 pilot hospital placed 195 long-acting reversible contraceptives during the first 5 months of the initiative. During this trial period, setbacks in the reimbursement process occurred for both the hospital and payer groups. The Agency for Health Care Administration was instrumental in providing assistance to overcome these setbacks. Although there were obstacles and setbacks along the way, this initiative was finally a success for our providers and patients. We encourage other hospitals and states to implement their own postpartum long-acting reversible contraceptive initiative with the use of the guidelines set forth by Florida's Access LARC initiative.

New Billing Rules for Outpatient Office Visit Codes

Guidelines for clinical documentation of evaluation and management face-to-face services were developed > 20 years ago. Recently, the Centers for Medicare & Medicaid Services (CMS) have addressed office and other outpatient services and the corresponding reimbursement, intending to reduce the amount of required documentation and to alleviate clerical burden. A CMS final rule for 2021 will eliminate the history and physical examination as criteria for level of service, allow time or medical decision-making to be used as coding criteria, and will recognize a code for prolonged service. The net effect of these changes may be some decrease in documentation burden, a change in the composition of clinical notes, and greater recognition by CMS of primary care and those who see highly complex patients requiring prolonged services.

Utilization of ACP CPT codes among high-need Medicare beneficiaries in 2017: A brief report

Importance

Medicare beneficiaries with high medical needs can benefit from Advance Care Planning (ACP). Medicare reimburses clinical providers for ACP discussions, but it is unknown whether high-need beneficiaries are receiving this service.

Objective

To compare rates of billed ACP discussions among a cohort of high-need Medicare beneficiaries with the non-high-needs Medicare population.

Design

Retrospective analysis of Medicare Fee-for-Service (FFS) claims in 2017 comparing high-need beneficiaries (seriously ill, frail, ESRD, and disabled) with non-high need beneficiaries.

Setting

Nationally representative FFS Medicare 20% sample

Participants

Medicare beneficiaries were assigned to one of the following classifications: seriously ill (65+), frail (65+), seriously ill & frail (65+); non-high need (65+); end stage renal disease (ESRD) or disabled (<65). All participants had data available for years 2016–2017.

Exposure

Receipt of a billed ACP discussion, CPT codes 99497 or 99498.

Main outcome and measure

Rates of billed ACP visits were compared between high-need patients and non-high-need patients. Rates were adjusted for the 65+ population for sex, age, race/ethnicity, Charlson comorbidity index, Medicare/Medicaid dual eligibility status, and Hospital Referral Region.

Results

Among the 65+ groups, those most likely to have a billed ACP discussion included seriously ill & frail (5.2%), seriously ill (4.2%), and frail (3.3%). Rates remained consistent after adjusting (4.5%, 4.0%, 3.1%, respectively). Each subgroup differed significantly (p < .05) from non-high need beneficiaries (2.3%) in both unadjusted and adjusted analyses. Among the <65 high need groups, the rates were 2.7% for ESRD and 1.3% for the disabled (the latter p < .05 compared with non-high needs).

Conclusions and relevance

While rates of billed ACP discussions varied among patient groups with high medical needs, overall they were relatively low, even among a cohort of patients for whom ACP may be especially relevant.

Hospital Medicine Has a Specialty Code. Is the Memo Still in the Mail?

The Centers for Medicare and Medicaid Services awarded Hospital Medicine a Medicare specialty code, "C6", in 2016. We examined the early uptake of C6 code using the 2017 Medicare Part B utilization data. We also compared the actual C6 specialty code usage against estimated rates of overall hospitalist billing using threshold-based hospitalist rates of Evaluation and Management codes to assess the integration of the newly introduced code. Billing activity associated with the C6 code was approximately one-tenth of expected rates.

Ambiguous Nomenclature in Musculoskeletal Magnetic Resonance Imaging

INTRODUCTION

Medical vocabulary that conveys different meanings to different groups of readers can lead to confusion and potential misinterpretation of diagnoses. This article reviews words used by radiologists that convey information to the orthopedic surgeon and patient that is different from what the radiologist intended. These terms include meniscal tears, ligament sprains, partial tendon tears, bone bruises, bone contusions, articular cartilage injury, disc bulges, disc herniations, and joint subluxation. These words can, for example, suggest a traumatic etiology when in fact the condition is atraumatic, and they can imply a surgical treatment where none is indicated. This problem is further magnified in the arena of personal injury litigation.

MATERIALS AND METHODS

The terms tear, bruise, contusion, injury, sprain, bulge, herniation, and subluxation are defined and analyzed for their ambiguous use, i.e., their actual versus intended meaning or other interpretation.

RESULTS

Abnormalities and variations observed on musculoskeletal magnetic resonance (MR) images are often multi-factorial and may not be the source of any given patient's symptoms. The same MR image findings can have a congenital, traumatic, or degenerative source.

CONCLUSIONS

Radiology vocabulary that invokes a singular traumatic event as a cause of an MRI finding can significantly mislead patients (as well as judges and juries). We propose that some terms be either avoided entirely when the findings are of uncertain etiology. At the very least, the various meanings of the terms need to be spelled out. Greater cooperation between orthopedic surgeons and radiologists on this matter would be beneficial to patient care.

Coding for Otolaryngology Office Procedures

This review article provides a summary of current correct coding for in-office surgical procedures. The relevant Current Procedural Terminology codes are covered and tips and guidance provided for their correct use. Also, where applicable, facility versus nonfacility reimbursement policy and the associated implications for physicians practicing in hospital-based clinics are discussed.

Are Orthopaedic Surgeons Performing Fewer Arthroscopic Partial Meniscectomies in Patients Greater Than 50 Years Old? A National Database Study

PURPOSE

To report the trends in arthroscopic partial meniscectomy (APM) for degenerative meniscal tears in a large private insurance database among patients older than 50 years.

METHODS

The Humana database between 2007 and 2015 was queried for this study. Patients meeting the inclusion criteria with degenerative meniscal tears who underwent APMs were identified by International Classification of Diseases, Ninth Revision codes, followed by Current Procedural Terminology codes. A linear regression analysis was performed with a significance level set at F < 0.05.

RESULTS

A total of 21,759 APMs were performed between 2007 and 2015 in patients older than 50 years. Normalized data for total yearly enrollment showed a significant increase in APMs performed from 2007 to 2010 (R² = 0.986, P = .007). The average percentage increase per year from 2007 to 2010 was 18.59%. However, there was a significant decrease in APMs performed from 2010 to 2015 (R² = 0.748, P = .026). The average percentage decrease per year from 2010 to 2015 was 7.74%. The percentage decrease overall from 2010 to 2015 was 71.68%. No difference in statistical significance was found when age was broken into 5-year age intervals. We found a significant difference in APM based on region (P < .001).

CONCLUSIONS

The rate of APMs in patients older than 50 years increased from 2007 until 2010. Since 2010, the rate of APMs in patients older than 50 years has significantly decreased. These trends are likely multifactorial. Regardless of cause, it appears that the orthopaedic surgery community is performing fewer APMs in this patient population.

LEVEL OF EVIDENCE

Level III, retrospective database epidemiological study.

New diagnostic procedure codes and reimbursement

With the implementation of the new Medicare Physician Fee Schedule on January 1, 2019, it can be beneficial for all practitioners to grasp an understanding of how reimbursement is determined. With the new Physician Fee Schedule also came new relative value units (RVUs) and new billing codes. Biopsy codes, in particular, were changed to reflect the complexity of the sampling technique (ie, tangential, punch, incisional). In this article, we explain RVUs and how they determine reimbursement. This article also highlights changes and additions to billing codes, specifically for biopsies and telemedicine services.