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PubMed1999

Understanding the Bone Mass Measurement Act.

The Bone Mass Measurement Act (BMMA) set forth regulations to provide for uniform coverage under Medicare Part B for bone mass measurements for services provided on or after July 1, 1998. The BMMA authorizes Medicare coverage of "medically necessary approved measurements" performed for a "qualified individual" who falls into at least one of five diagnostic categories: an estrogen-deficient woman at clinical risk for osteoporosis; an individual with vertebral abnormalities; an individual receiving long-term glucocorticoid (steroid) therapy; an individual with primary hyperparathyroidism; and an individual being monitored to assess the response to, or efficacy of, an approved osteoporosis drug therapy. Proper communication is essential for reimbursement. The tools for communication include Physician's Current Procedural Terminology (CPT), HCFA (Health Care Financing Administration) Common Procedure Coding System (HCPCS), the Medicare carrier's local Medical Review Policy (LMRP), and the International Classification of Diseases, ninth revision (ICD-9). This article reviews the new regulations and the tools for communication.

Absorptiometry, Photon↗
PubMed1997

Children's health care use in the Healthy Kids Program.

BACKGROUND: In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix. METHODS: Each HMO provided child-specific health care use data including Physician's Current Procedural Terminology codes and International Classification of Diseases, 9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate chi2 statistics. RESULTS: A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 +/- 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences. CONCLUSIONS: The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program.

Child↗
PubMed1998

Impact of a Medicaid primary care provider and preventive care on pediatric hospitalization.

OBJECTIVE: This study evaluates the impact that a Medicaid managed care program had on avoidable hospitalization, a form of health care misuse that we hypothesize can be reduced by improved access to and quality of primary care in the context of a managed care program. Ambulatory care sensitive (ACS) hospitalizations, a previously defined categorization of hospitalization, as well as all pediatric hospitalizations were also studied. INTERVENTION: The Maryland Access to Care (MAC) was a fee-for-service, gatekeeper, Medicaid managed care program with assigned primary medical providers and required Early Periodic Screening, Diagnosis, and Treatment (EPSDT) examinations. Medicaid managed care elements include: 1) assignment to primary medical provider (PMP) either by voluntary choice or mandatory enrollment of eligible Aid to Families With Dependent Children (AFDC), Medical Assistance (medical needy), and Supplemental Security Income; 2) a medical home accessible 24 hours a day, 7 days a week; 2) PMP must authorize emergency department (ED), inpatient, and specialty care but there were no disincentives to PMP for referral; 3) fee-for-services reimbursement (with a physician rate increase) for primary care, authorized specialist care, and hospitalization; and 4) an on-line eligibility verification system was available to all medical providers. Pre-enrollment as well as publicity allowed MAC to be phased in rapidly, resulting in 70% to 80% enrollment by the end of the first program year. DESIGN: The design of this study is that of a pre- and postevaluation of the MAC program using Medicaid claims analysis of data 3 years pre-MAC and 2 years post-MAC. In multivariate analyses, this study also compares MAC-enrolled children to non-MAC-enrolled children (before and after MAC began) to estimate the impact of MAC enrollment while controlling for potential confounders. SETTING: State of Maryland from 1989 to 1993. PATIENTS: MAC-eligible children 18 years of age. OUTCOME MEASURES: Claims data were used to define avoidable hospitalization (based on ambulatory care received before hospitalization), to define ACS hospitalizations (based on the International Classification of Diseases-Clinical Modification, Ninth Revision [ICD-9-CM] codes), and to summarize use of ambulatory and inpatient care. ACS hospitalizations have been defined as those conditions for which timely and effective primary care can help to reduce the risk of hospitalizations. These are based solely on ICD-9-CM discharge codes that were studied by Billings and Teicholz in 1990 and used by an Institute of Medicine report in 1993. Examples include hospital discharge diagnoses of asthma (ICD-9-CM = 493), gastroenteritis (ICD-9-CM = 558.9), and dehydration (ICD-9-CM = 276.5). Usage measures, such as preventive care visits or ED visits, were created using Maryland Medicaid codes, Current Procedural Terminology codes, and ICD-9-CM codes. Linear regression was used to model trend. Logistic regression was used to model the probability of ambulatory and inpatient care given MAC enrollment and other covariates. First, logistic regression was used to predict the probability of any ambulatory care use among all MAC-eligible children during a quarter to model changes in access that may have occurred during MAC. Then, among users of ambulatory care or inpatient care, logistic regression was used to predict the probability of hospitalization. RESULTS: Most of the children studied were in the AFDC program, about half were African-American, one third resided in Baltimore City, and 9% of children had ICD-9-CMs reflecting chronic disease. The mean percentage of time children were MAC-eligible per quarter was 91%. Only 5% of children were continuously enrolled for all 20 quarters included in this study. Per-capita ambulatory care visits, especially per-capita preventive care visits, increased significantly during the study period (b = 0.003) whereas per-capita ED visits did not change. The mean n

Adolescent↗
PubMed2001

What if pediatric residents could bill for their outpatient services?

OBJECTIVE: We prospectively studied the potential of billing and coding practices of pediatric residents in outpatient clinics and extrapolated our results to assess the financial implications of billing inaccuracies. Using Medicare as a common measure of "currency," we also used the relative value unit (RVU) and ambulatory payment class methodologies as means of assessing the productivity and financial value of resident-staffed pediatric clinics. METHODS: Residents were asked to submit voluntarily shadow billing forms and documentation of outpatient clinic visits. Documentation of work was assessed by a blinded reviewer, and current procedure terminology evaluation and management codes were assigned. Comparisons between resident codes and calculated codes were made. Financial implications of physician productivity were calculated in terms of dollar amounts and RVUs. Resource intensity was measured using the ambulatory payment class methodology. RESULTS: A total of 344 charts were reviewed. Coding agreement for health maintenance visits was 86%, whereas agreement for acute care visits was 38%. Eighty-three percent of coding disagreement in the latter group was resulting from undercoding by residents. Errors accounted for a 4.79% difference in potential reimbursement for all visit types and a 19.10% difference for acute care visits. No significant differences in shadow billing discrepancies were found between different levels of training. Residents were predicted to generate $67 230, $87 593, and $96 072 in Medicare revenue in the outpatient clinic setting during each successive year of training. On average, residents generated 1.17 +/- 0.01 and 0.81 +/- 0.02 work RVUs for each health maintenance visit and office visit, respectively. Annual productivity from outpatient clinic settings was estimated at 548, 735, and 893 work RVUs in the postgraduate levels 1, 2, and 3, respectively. CONCLUSION: When pediatric residents are not trained adequately in proper coding practices, the potential for billing discrepancies is high and potential reimbursement differences may be substantial. Discussion of financial issues should be considered in curriculum development.

Accounting↗
PubMed2002

Regional after-hours urgent care provided by a tertiary children's hospital.

BACKGROUND: Ambulatory presentation to a tertiary pediatric emergency department (ED) is not convenient for many families. Yet many primary care pediatricians (PCPs) desire after-hours urgent care for their patients as an alternative to extended office hours or care by general emergency medicine providers at community hospitals. OBJECTIVE: To describe a regional, community-based pediatric urgent care network (PUCN). METHODS: The PUCN consists of 4 models: 1) pediatric emergency medicine faculty in a community hospital ED; 2) general pediatricians in a community hospital ED; 3) general pediatricians in a freestanding urgent care center; and 4) general pediatricians in a community hospital-based urgent care center. Physician staffing at all 4 sites is managed by our tertiary children's hospital. Billing records were reviewed and a questionnaire was mailed to 55 PCP practices in our metro area. RESULTS: Year 2001 visits totaled 37 143. Minor trauma, ear complaints, and viral illnesses accounted for 70% of visits. Current Procedural Terminology codes for visits, reflecting complexity levels 1, 2, 3, 4, and 5 were billed at the following frequency: 1%, 35%, 44%, 17% and 3%, respectively. A total of 2.2% of visits required admission or transfer. Mean collection rates ranged from 37% to 68% across the 4 sites. Break-even average hourly patient volumes ranged from 1.1 (site 4) to 1.9 (sites 1 and 3). A total of 110 PCPs, representing all 55 practices, responded to the questionnaire: 81% reported their patients used the PUCN often, 85% felt that communication between the PUCN and their practice was good, and 99% reported overall satisfaction with the network. CONCLUSIONS: The PUCN effectively addresses the needs of regional PCPs; however, the cost-effectiveness of such a program depends on billing practices, local collection rates, and site-specific staffing patterns.

After-Hours Care↗
PubMed2004

Application of the resource-based relative value scale system to pediatrics.

In today's rapidly changing health care environment, it is crucial to understand the genesis and principles behind the Medicare Resource-Based Relative Value Scale (RBRVS) physician fee schedule. Many third-party payers, including state Medicaid programs, BlueCross BlueShield, and managed care organizations, use variations of the Medicare RBRVS to determine physician reimbursement and capitation rates. Because the RBRVS fee schedule was created originally for Medicare only, pediatric-specific Current Procedural Terminology (CPT) codes and pediatric practice expense calculations were not included. The American Academy of Pediatrics supports the use of CPT codes and the RBRVS physician fee schedule and continues to work to rectify certain inequities of the RBRVS system as they pertain to pediatrics.

Forms and Records Control↗
PubMed2006

Cost-effectiveness analysis of antithrombotic therapy in nonurgent percutaneous coronary intervention.

STUDY OBJECTIVE: To perform a cost-effectiveness analysis comparing three treatment approaches during nonurgent percutaneous coronary intervention (PCI): bivalirudin with provisional glycoprotein (GP) IIb-IIIa inhibitor therapy, unfractionated heparin (UFH) with eptifibatide, and UFH with abciximab. DESIGN: Literature-based decision model from an institutional perspective. DATA SOURCE: Patient data from the Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events (REPLACE)-2 study and three other randomized controlled trials that included UFH and routine GP IIb-IIIa inhibitor (eptifibatide or abciximab) therapy. All included studies were comparable based on patient population, procedural techniques, and general treatment approaches. MEASUREMENTS AND MAIN RESULTS: We included patient populations undergoing contemporary nonurgent PCI to identify probabilities of success or complications (myocardial infarction, urgent revascularization, thrombocytopenia, and major or minor bleeding at 30 days). Costs were assigned to each outcome by incorporating diagnosis-related group-- and/or Current Procedural Terminology--associated costs, institutional drug acquisition costs, and unit replacement costs of platelets and red blood cells. In the base-case analysis, the use of bivalirudin with provisional GP IIb-IIIa inhibitor therapy dominated the UFH and planned GP IIb-IIIa inhibitor approach: UFH with eptifibatide was 74 US dollars more expensive and 1.2% less effective, and UFH with abciximab was 777 US dollars more expensive and 2.3% less effective. Sensitivity analyses indicated that the model results were robust, but also revealed that bivalirudin lost its cost-effectiveness, resulting in UFH with eptifibatide becoming more cost-effective, when two or more vials of bivalirudin were necessary in greater than 27% of cases or when the use of provisional GP IIb-IIIa inhibitor therapy exceeded 20%. CONCLUSION: This analysis indicates that bivalirudin with provisional GP IIb-IIIa inhibitor therapy is the most cost-effective antithrombotic treatment strategy in nonurgent PCI when its use and dosing are consistent with the REPLACE-2 trial.

Abciximab↗
PubMed2006

Cardiac rehabilitation and survival of dialysis patients after coronary bypass.

Patients who are on renal dialysis are at high risk for cardiac death and have a large burden of cardiovascular disease and cardiovascular disease risk factors. Cardiac rehabilitation can promote improved survival of nondialysis patients after coronary artery bypass grafting (CABG) surgery and is covered by Medicare, but no previous studies have investigated whether dialysis patients' survival after CABG may be improved as a function of cardiac rehabilitation. A prospective cohort study was conducted using Medicare claims (1998 to 2002) for CABG and cardiac rehabilitation and patient information from the United States Renal Data System database for 6215 renal patients who initiated hemodialysis and underwent CABG between January 1, 1998, and December 31, 2002, with mortality follow-up to December 31, 2003. Cardiac rehabilitation was defined by Current Procedural Terminology codes for monitored and nonmonitored exercise in Medicare claims data. Dialysis patients who received cardiac rehabilitation after CABG had a 35% reduced risk for all-cause mortality and a 36% reduced risk for cardiac death compared with dialysis patients who did not receive cardiac rehabilitation, independent of sociodemographic and clinical risk factors, including recent hospitalization. Only 10% of patients received cardiac rehabilitation after CABG, compared with an estimated 23.4% of patients in the general population, and lower income patients of all ages as well as women and black patients who were aged 65+ were significantly less likely to receive cardiac rehabilitation services. This observational study suggests a survival benefit of cardiac rehabilitation for dialysis patients after CABG.

Aged↗
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↗
PubMed1998

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

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

Ambulatory Care↗
PubMed2005

A nursing home telehealth system: keeping residents connected.

Live video and detailed images of nursing home residents can be transmitted in real time via the Internet. This telehealth system allows residents and long-term care health professionals to connect with experts not available on-site. Electronic stethoscope, otoscope, dermascope, dentalscope, and electrocardiogram are available for use via the Internet. Impediments to implementing telehealth systems in long-term care include costs and the lack of reimbursement for telehealth services. Reimbursement for telemedicine in nursing homes is limited by originating site, current procedural terminology codes, and facility location.

Aged↗
PubMedDate not supplied

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

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

Journal Article↗
PubMedDate not supplied

Practical tips on coding for diabetes care.

This article is designed to assist with the challenging effort to obtain reimbursement for health-care services to patients with diabetes. The basics of coding diagnoses and services are presented, including background information and specific examples of the use of codes that are particularly pertinent to the clinical endocrinologist's care of the patient with diabetes. The coding of diagnoses with use of the current International Classification of Diseases, 9th revision, clinical modification (ICD-9-CM) classification system and the coding of outpatient and inpatient services by using current procedural terminology (CPT) codes and modifiers are outlined, including the use of the relatively new prolonged physician services codes. A discussion of reimbursement for diabetes education and pertinent revenue codes for hospital services is included, and resource references for further study are provided.

Journal Article↗
PubMedDate not supplied

Diagnosis and procedure coding for bone mass measurement.

OBJECTIVE: To provide background information and practical advice about coding for submission of claims for reimbursement for performing bone mass measurement studies. METHODS: The current procedural terminology (CPT) codes for diagnoses and procedures related to reduced bone mass and osteoporosis are reviewed, and Medicare and other payer policies are discussed. RESULTS: Although considerable differences exist in payer policies relative to bone mass measurement, notable consistency is developing for Medicare patients. The CPT codes for pertinent outpatient and inpatient services, and applicable CPT modifiers, are outlined. In addition, examples are provided of criteria imposed for qualification for coverage. If a carrier or payer is not expected to provide coverage for the performance of a bone mass measurement study, an advance beneficiary notice (waiver statement) should be processed and the patient should be informed about the potential responsibility for payment before the test is done. CONCLUSION: Osteoporosis is an important and costly disorder that is rapidly increasing in prevalence in our society. Clinical endocrinologists have a critical role in the management of patients with this condition and an opportunity to contribute to high-quality care. Proper selection of patients for assessment and treatment and an understanding of certain restrictions and necessary documentation for insurance coverage may help obtain reimbursement for their care.

Bone Density↗
PubMedDate not supplied

Onychauxic dystrophic toenails requiring debridement in Medicare patients. Prevalence and anatomical distribution.

Six hundred twenty-nine Medicare patients were evaluated for the presence of onychauxic toenails that in the judgment of the examiners required reduction. Forty-two percent of this group had five or fewer toenails requiring reduction and 24.3% had six or more toenails requiring reduction. Statistics reported by a regional Medicare-contracted carrier for the years 1997 to 1999 showed that 95% of claims submitted for nail debridement were for six or more nails and 5% were for five or fewer nails. The 1999 Medicare Part B data listed the top 300 Current Procedural Terminology (CPT) foot-care codes in order of utilization. Code 11721 (debridement of six or more nails) was number one. National statistics from the Health Care Financing Administration in 1999 indicated approximately a 5:1 ratio in favor of CPT code 11721 (six or more nails). In contrast, this study found a ratio of 2:1 in favor of CPT code 11720 (five or fewer nails).

Aged↗
PubMed1993

Physician performance standard rates of increase for federal fiscal year 1994 and physician fee schedule update for calendar year 1994--HCFA. Final notice with comment period.

This notice announces the calendar year (CY) 1994 updates to the Medicare physician fee schedule and the Federal fiscal year (FY) 1994 performance standard rates of increase for expenditures and volume of physicians' services under the Medicare Supplementary Medical Insurance (Part B) program as required by sections 1848 (d) and (f), respectively, of the Social Security Act. The physician performance standard rates of increase for Federal FY 1994 are 8.6 percent for surgical services, 10.5 percent for primary care services, 9.2 percent for other nonsurgical services, and 9.3 percent for all physicians' services. The fee schedule update for CY 1994 is 10.0 percent for surgical services, 7.9 percent for primary care services, and 5.3 percent for other nonsurgical services. This notice also references the surgical and nonsurgical designations for new and revised procedure codes in the Physicians' Current Procedural Terminology, to be used in applying the CY 1994 updates and for establishing and measuring expenditures under the MVPS for FY 1994. These designations appear in Addendum C of the final rule with comment period entitled "Medicare Program; Revisions to Payment Policies and Adjustments to the Relative Value Units under the Physician Fee Schedule for Calendar Year 1994 (BPD-770-FC)," published elsewhere in this Federal Register issue. The new and revised surgical and nonsurgical designations are subject to public comment. In addition, this notice addresses public comments on the "initial" procedure-specific list of surgical services published in our November 25, 1992, notice.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1990

Medicare program; definition of surgical services--HCFA. Notice of definition of surgical services for physician volume performance standard rates for increase with comment.

This notice announces the definition of surgical services for purposes of the performance standard rates of increase for expenditures and volume of physician services and the appropriate fee schedule updates under the Medicare Supplementary Medical Insurance (Part B) program as required by section 6102 of the Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101-239). Surgical services are defined as follows: All services currently classified as type of service "surgery" in the Medicare payment record that are performed by surgical specialists, including podiatrists and oral surgeons. All services currently classified as type of service "assistant at surgery" in Medicare payment records. This definition includes procedures recognized in the surgical section of Current Procedural Terminology published by the American Medical Association and certain other invasive procedures. This definition would not lead to payment differentials by physician specialty. Any differential in annual updates because of separate performance standard rates would be procedure-specific without regard to specialty.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1998

Clinical buy-in is key to benchmarking success.

The effectiveness of benchmarking as a tool for improving the quality of healthcare services and reducing costs depends on the completeness of the data and physician acceptance of the findings. Benchmarking analyses based on cost-center data, for example, do not account for many of the actual costs of performing a procedure and, therefore, may be of limited value. Benchmarking studies should use data that provide a complete, detailed picture of what each procedure entails to facilitate consistent comparisons among actual physician practices so that physicians can see clearly how their practices relate to best practices. The current procedural terminology (CPT) coding system can provide an excellent basis for assembling benchmark data.

Abstracting and Indexing↗