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PubMed1991

Supportive periodontal treatment: maintenance.

An increasing emphasis is being placed on the phase following active therapy for inflammatory periodontal diseases. This phase of therapy, once termed maintenance, is now called supportive periodontal therapy (SPT) (American Academy of Periodontology, Current Procedural Terminology for Periodontics. 5th American Academy of Periodontology, 1986). Supportive periodontal therapy has been shown to have an important role in controlling periodontal problems. However, most patients do not comply with suggested SPT intervals.

Continuity of Patient Care↗
PubMed1991

Billing practices of North Carolina family physicians.

BACKGROUND: This study describes billing practices of family physicians. Significant increases in the reimbursement for family physicians are expected from implementation of the resource-based relative value scale (RBRVS). However, the real impact of the RBRVS is unknown since little is known about how family physicians use the present reimbursement system to charge their patients. METHODS: A random sample of 270 North Carolina family physicians was surveyed, using standardized progress notes of five hypothetical patients. RESULTS: One hundred thirty-eight (51%) physicians responded; 107 (77.5%) were in private practice. Family physicians in private and nonprivate practices were similar in their Current Procedural Terminology (CPT) coding and level of service for each hypothetical case. Family physicians in smaller communities showed greater variation in CPT coding of visits than did family physicians in larger communities, and they were more likely to use CPT codes that indicated a lower level of visit. Rural family physicians demonstrated a significant inverse relationship between the CPT level of visit coded (ranging from "brief," with a CPT code of 90040, to "comprehensive," coded CPT 90080) and the amount they charged established patients for a "limited" visit (CPT 90050). CONCLUSIONS: These findings suggest that the lower income of rural physicians is due, in part, to billing at a lower CPT code, and thus charging less for comparable services, than urban physicians. The findings also lend further support to contentions that federal reimbursement reforms will have less impact on the incomes of rural physicians than originally expected.

Abstracting and Indexing↗
PubMed1991

The adequacy of physician reimbursement for pediatric care under Medicaid.

This article examines 1989 Medicaid physician reimbursement for pediatric care in 47 states and the District of Columbia. To assess the adequacy of payment, several state reimbursement policies were analyzed, including physician payment methods, frequency of payment updates, and fee data for five common evaluation and management codes and two Early and Periodic Screening, Diagnosis, and Treatment visit categories. Physician payment rates were evaluated to determine overall state and regional patterns of Medicaid reimbursement. They were also compared with regional private market fee data and average national Medicare fees to assess their adequacy. The majority of state Medicaid programs used fixed fee schedules as their physician reimbursement method. Nearly one fourth of states that update their fees overall by physician specialty have not adjusted their rates since 1985 or before. Medicaid reimbursement rates for five commonly used evaluation and management Physicians' Current Procedural Terminology (4th ed) office visit codes and Early and Periodic Screening, Diagnosis, and Treatment screening and follow-up examinations varied substantially across states and among regions. States in the West paid the highest rates for most office visits, while Northeastern states generally paid the least. A comparison of Medicaid payment rates with private market fee data revealed that Medicaid payments for established patients averaged less than two thirds of market rates for pediatricians, family physicians, and general practitioners. New patient care is reimbursed somewhat better. Regional variations are substantial. In addition, a comparison of Medicaid payment rates with 1988 Medicare fee data showed that average Medicaid reimbursement rates were less than four fifths of average allowed Medicare charges. Policy implications include the need to increase Medicaid rates so that they are much closer to private insurance and Medicare rates, particularly in the Northeast and in selected states, in order to increase participation by pediatric providers in Medicaid. In addition, efforts to re-evaluate reimbursement relative to level of service, as used in Medicare's resource-based relative value scales, deserve further research. Finally, comparable access to comprehensive pediatric care especially in underserved urban areas will require not only improvements in physician reimbursement but also more deliberate efforts to affect the maldistribution of mainstream medical care. Approaches to measure the impact of enhanced reimbursement on access to care by Medicaid-eligible children are discussed.

Delivery of Health Care↗
PubMed1990

Variations in coding practices among Connecticut urologists for the Medicare population.

As health care costs continue to rise, alternatives to the traditional fee for service system of physician reimbursement are being explored. Recently a resource-based relative-value system was enacted by Congress to correct some of the perceived inequities of Medicare reimbursement. Since reimbursement for evaluation and management services, also known as cognitive services, are based on Current Procedural Terminology (CPT-4) codes, we reviewed Medicare claims data for fiscal year 1986-87 to identify the coding habits of Connecticut urologists. We found that Connecticut urologist file 99% of their claims for cognitive services in one of six categories. Furthermore, we found that within these broad categories an average of 82% of the claims were filed under one primary practice specific code. The particular code selected, however, varied markedly between practices. Our data suggest that Connecticut urologists have adopted different standards for using CPT-4 codes and have adjusted for these differences through their fee schedules. These findings highlight the need for increased precision in CPT code definitions for cognitive services before they can be adapted to a reimbursement system based upon relative-value scales.

Abstracting and Indexing↗
PubMed1988

Extrapolation of measures of work for surveyed services to other services.

A national survey of physicians produced detailed data on the work involved in performing 372 different services. This article describes methods developed to extrapolate the study data to a larger universe of services, defined by the Physicians' Current Procedural Terminology, edition 4. Because data measuring work inputs for nonsurveyed services presently are unavailable, we devised an extrapolation method that makes use of available charge data without building their inherent distortions into the extrapolated scale. To neutralize the effect of these distortions, we used small, homogeneous families of services as the basic units for the extrapolations and assumed that charges are reasonable indicators of relative work within such families. To produce extrapolated work values within each family, we multiplied an estimate of work based on survey data for a benchmark procedure by charge-based ratios that represent the relationships between surveyed and nonsurveyed services. These extrapolations can be used in constructing a Resource-Based Relative Value Scale.

Clinical Laboratory Techniques↗
PubMed1988

Evaluation and management services in the Resource-Based Relative Value Scale.

Evaluation and management (E/M) services, which include making diagnoses, counseling and educating, developing strategies of care, and following up on treatment, are common to all medical specialties. Surveys of a variety of specialists using the magnitude-estimation method show that physicians agree closely in rating the work of particular E/M services. Regardless of the type of E/M service, the site at which it is performed, or the specialty performing it, work per unit of time varies only slightly. Comparison of work and time for services to which experts assigned billing codes in our consultative process indicates, however, that there may be large differences in the way different specialties use these billing codes. In some instances, work entailed by some of the E/M billing codes within specialties also appears to vary substantially. If empirical studies of physicians' coding and billing practices support our findings, possible responses might include (1) developing specialty-specific resource-based relative values for E/M services and (2) redefining the Physicians' Current Procedural Terminology, edition 4, codes for these services in terms that include time specifications.

Economics, Medical↗
PubMed1983

A system for reporting gynecologic procedures. A linguistic-logical approach.

A system was developed for reporting gynecologic procedures at Chicago Lying-In Hospital. The system is designed to report procedures and treatments performed during both inpatient stays and outpatient visits. Key features of the system are (1) the automatic encoding of all gynecologic procedures in both the ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) coding systems, (2) the use of an independent program to maintain and update a multiply referenced network of operative procedures and (3) the use of a cross-indexing system that allows each procedure to be accessed in several ways and according to several patterns of keys (billing code number, CPT category, common abbreviation and/or linguistic feature).

Computers↗
PubMed1995

Resource-Based Relative Value Scales: impacts and recommendations relative to chiropractic practice.

PURPOSE: The American health care financing and delivery system is changing at a rapid pace. As part of recent reform of payment systems for physician services, Medicare has adopted a resource-based relative value scale (RBRVS) that is becoming a national standard. Research has now documented characteristics of physicians' work and the overhead for providing specific health services for most medical specialties and disciplines. This information is being used to develop service descriptions (billing codes) and reimbursement levels. No such data exist relative to chiropractic, which may hinder chiropractic's efforts to be included in evolving reimbursement schemes. RBRVS and its relevance to chiropractic is reviewed, information on work levels and practice costs is discussed, chiropractic practice is reviewed and a research and policy agenda for documenting chiropractic work, overhead and service descriptions is provided. METHODOLOGY: A manual systemic review of available recent and relevant medical and chiropractic literature was undertaken to characterize how the RBRVS system for reimbursement of physician services was developed and implemented. Payer and trade association literature was used to determine what established work value and practice costs for DCs there are. Published payment scales from governmental commissions were also obtained. CONCLUSIONS: Resources are urgently needed to survey levels of work by chiropractors in providing their various health services. The methodology should be the one used by the Health Care Financing Administration to assess other specialties. A range of generic manipulation codes should be developed and tested in a similar fashion for submission for inclusion in Physician's Current Procedural Terminology (CPT). A seed range of descriptions is presented. A systematic collection of practice overhead costs and malpractice risk should be undertaken and documented using standardized methodology.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1993

The health care status of the diabetic population as reflected by physician claims to a major insurer.

BACKGROUND: Conventional epidemiologic data suggest that diabetic patients use more health care resources than nondiabetic patients, yet overall health care use by diabetic individuals has never been fully quantitated. We took a new approach to this issue based on the actual economics of the provision of health care to diabetic insured individuals. METHODS: The claims records in the Mutual of Omaha Current Trends database, which contains information on more than 400,000 individuals, were surveyed to identify patients with diabetes and create the contrast population of nondiabetic patients by exclusion. International Classification of Diseases, Ninth Revision, Clinical Modification, codes and Physicians' Current Procedural Terminology, Fourth Edition, codes were used to determine all diagnoses recorded and all physician services rendered to the contrast populations. Age- and sex-adjusted comparisons were performed using Mantel-Haenszel procedures to determine an adjusted odds ratio (AOR). RESULTS: A total of 13,304 diabetic individuals and 388,053 nondiabetic individuals who received health care services from January 1, 1988, to January 1, 1989, were identified. Diabetic insured individuals constituted 3.1% of the overall insured population yet accounted for 8.3% of the charges (P < .01). Inpatient charges accounted for 81% of total diabetic charges but only 61.5% of total nondiabetic charges (P < .001). Diabetic insured individuals had twice as many physician office visits (AOR = 1.87; 95% confidence interval [CI], 1.79 to 1.96), with 2.5 times more physician hospital visits [AOR = 2.50; 95% CI, 2.27 to 2.75). However, the increases in physician care were not uniformly distributed across the diagnostic spectrum. The frequencies of well-established complications of diabetes, such as ischemic heart disease (AOR = 3.32; 95% CI, 3.12 to 3.53), peripheral vascular disease (AOR = 3.14; 95% CI, 2.79 to 3.53), and eye disease (AOR = 3.10; 95% CI, 2.94 to 3.27), were threefold higher in the diabetic group, with parallel increases in related medical services, such as cardiac catheterization (AOR = 3.02; 95% CI, 2.27 to 4.0), vascular surgery (AOR = 2.94; 95% CI, 2.64 to 3.27), and ophthalmologic procedures (AOR = 2.94; 95% CI, 2.72 to 3.18). In contrast, most diagnostic categories showed little or no increase. For example, the frequency of neoplasms (AOR = 1.11; 95% CI, 1.03 to 1.19) was minimally increased, and the associated procedural concomitants of therapeutic radiology (AOR = 0.81; 95% CI, 0.47 to 1.39) and chemotherapy (AOR = 0.98; 95% CI, 0.60 to 1.60) were not increased in the diabetic group. CONCLUSIONS: Our most important new finding is that diabetic patients have neither an elevated risk for a wide spectrum of diseases nor an increase in the receipt of physician services for diagnostic categories without increased risk, despite more frequent physician encounters. We provide real-world risk estimates that help in calculating the effect of offering specific insurance to diabetic individuals or including them in group health plans. The techniques we have developed to analyze computerized claims databases in this way may serve to better quantify the true impact of chronic diseases on the health care system.

Adult↗
PubMed1996

A pharmacoeconomic evaluation of cisplatin in combination with either etoposide or etoposide phosphate in small cell lung cancer.

To compare etoposide and etoposide phosphate (Etopophos; Bristol-Myers Squibb Company, Princeton, NJ) in maximizing the cost efficiency of care for patients with small cell lung cancer (SCLC), we obtained pharmacoeconomic data from a phase II randomized study of these agents. This clinical investigation assessed the efficacy and toxicity of etoposide phosphate combined with cisplatin in treating SCLC. In the economic analysis, we identified resources expended during chemotherapy and related concomitant procedures and matched them with the current procedure terminology level of costs for the provider and the payor. The valuation process was conducted in the specific point-of-care (outpatient v inpatient) setting. The appropriate pharmacoeconomic analytic tool used when comparators are considered to achieve equivalent clinical outcomes is cost-minimization analysis. We provide the cost-minimization analysis from two oncology care perspectives: the provider and the payor. In addition, a payor/ provider cost reduction model was constructed to illustrate the potential economic effects achieved through more efficient use of the outpatient chemotherapy facility due to the ease of administration of etoposide phosphate. The provider's average cost per patient for treating an SCLC patient for six cycles in US dollars is $26,764.48 for etoposide versus $26,026.70 for etoposide phosphate. The payor's average treatment cost per patient for treating an SCLC patient for six cycles for the respective regimens was $34,270.65 and $34,320.70. When the time savings associated with the etoposide phosphate regimen are applied to the outpatient chemotherapy facility, the adjusted average treatment costs per patient for the payor are $2,797.29 less than the costs for using the standard etoposide intravenous formulation. Delivering an etoposide phosphate regimen accrued adjusted savings of $2,897.03 per patient. Based on these results, etoposide phosphate is a superior pharmacoeconomic alternative compared with standard etoposide chemotherapy in managing SCLC. The potential increase in patient volume conferred by the relative simplicity of etoposide phosphate administration would have a significant impact on operations in terms of scheduling patients and staff and increasing operational efficiencies, thereby facilitating cost reductions in excess of $2,700 per patient when an etoposide phosphate regimen is chosen over an etoposide regimen.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1997

Resource-Based Relative Value Scale (RBRVS), coding, and Medicare reimbursement.

Many changes occurred during 1996 in the Resource-Based Relative Value Scale that determines physician payment for services to Medicare beneficiaries in 1997. These issues include the 5-year review of physician work values, the Correct Coding Initiative, changes in the surgical Conversion Factor, and a new Medicare payment formula. Likewise, several more changes on the horizon in 1997 will dramatically impact the 1998 Medicare Fee Schedule, primarily the upcoming resource-based Practice Cost Relative Value Scale, and possible elimination of the separate surgical Conversion Factors. There are also several new Current Procedural Terminology codes that will receive Medicare payment in 1997 and 1998. This article summarizes these events and issues from a vascular surgical perspective.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1997

Projecting corporate health plan utilization and charges from annual ICD-9-CM diagnostic rates: a value-added opportunity for pathologists.

OBJECTIVE: To develop an allocation method for corporate health plan resources and expenditures based on annual International Classification of Disease, 9th revision, Clinical Modification (ICD-9-CM) diagnostic rate stratification as a surrogate for disease incidence. DESIGN: A data-mining process was applied to a self-insured corporate health plan database. Annual membership rates of Current Procedural Terminology (CPT) procedure utilization and charges between 1990 and 1994 for a cohort of 7216 continuously employed plan members were stratified according to the annual rates of the 19 major ICD-9-CM diagnostic classifications. The stratified annual CPT utilization and charge rates were analyzed by correlation analysis and one-tailed t test. RESULTS: Laboratory and pathology procedure utilization and charge rates were highly correlated with specific rankings of ICD-9-CM diagnostic classifications. The health plan diagnostic rate, laboratory utilization rate, and all charge rates increased significantly during the 5 study years. CONCLUSION: Although all procedure utilization and charge rates in this health plan increased each year, their proportionality consistently was maintained among diagnostically related groups of patients. By restraining global expenditures, managed health plans conflict with historical utilization and charge patterns. Treating ICD-9-CM diagnostic groups as disease management services within a managed care plan allows procedures and expenses to be allocated according to medical necessity in the context of total membership benefits. For pathologists, who recently were mandated by the Health Care Financing Administration and the Office of Inspector General of the Department of Health and Human Services to become stewards of ICD-9-CM coding, this is a unique opportunity to lead an initiative to perfect managed care. The process will require permanent patient numbers, computerized longitudinal patient records, and standardized coded medical terminology.

Adult↗
PubMed1998

Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation.

BACKGROUND: Little is known about the accuracy of family physicians' use of the Current procedural Terminology (CPT) coding scheme for office visits, despite increased administrative oversight of Medicare billing practices. In addition, the patient and visit characteristics that are associated with over- and undercoding are not well understood. METHODS: This study compared coding for evaluation and management (E&M) services billed for 3791 visits to 138 family physicians with the codes assigned by trained research nurses using direct observation. We calculated the degree to which the codes for E&M were concordant with the observer-assigned codes. Analysis of variance and logistic regression were used to examine the association of visit and patient characteristics with discordance between billed and observer-assigned CPT codes. RESULTS: Billing codes were concordant for 55% of encounters. Discordance was evenly distributed between under- and overcoding. Concordance of billed and observed codes was greatest for patients with indemnity insurance. Undercoding increased with longer visit length and a smaller percentage of the visit spent planning treatment. Overcoding was more common during visits with a greater percentage of time spent chatting, planning treatment, and delivering preventive services. CONCLUSIONS: Family physicians are generally accurate in their billing procedures. The findings on patient and visit characteristics associated with over- or undercoding may be used by practicing clinicians to enhance the accuracy of their coding and billing procedures.

Adult↗
PubMed2000

Modeling the uncertainty of surgical procedure times: comparison of log-normal and normal models.

BACKGROUND: Medical institutions are under increased economic pressure to schedule elective surgeries efficiently to contain the costs of surgical services. Surgical scheduling is complicated by variability inherent in the duration of surgical procedures. Modeling that variability, in turn, provides a mechanism to generate accurate time estimates. Accurate time estimates are important operationally to improve operating room utilization and strategically to identify surgeons, procedures, or patients whose duration of surgeries differ from what might be expected. METHODS: The authors retrospectively studied 40,076 surgical cases (1,580 Current Procedural Terminology-anesthesia combinations, each with a case frequency of five or more) from a large teaching hospital, and attempted to determine whether the distribution of surgical procedure times more closely fit a normal or a log-normal distribution. The authors tested goodness-of-fit to these data for both models using the Shapiro-Wilk test. Reasons, in practice, the Shapiro-Wilk test may reject the fit of a log-normal model when in fact it should be retained were also evaluated. RESULTS: The Shapiro-Wilk test indicates that the log-normal model is superior to the normal model for a large and diverse set of surgeries. Goodness-of-fit tests may falsely reject the log-normal model during certain conditions that include rounding errors in procedure times, large sample sizes, untrimmed outliers, and heterogeneous mixed populations of surgical procedure times. CONCLUSIONS: The authors recommend use of the log-normal model for predicting surgical procedure times for Current Procedural Terminology-anesthesia combinations. The results help to legitimize the use of log transforms to normalize surgical procedure times before hypothesis testing using linear statistical models or other parametric statistical tests to investigate factors affecting the duration of surgeries.

Databases, Factual↗
PubMed2003

[Facial clefts and their coding with LAHS nomenclature].

Research and treatment of clefts of lip, alveolus, and palate requires exact, reliable and reproducible terminology and documentation. In this paper we suggest a simple system to record a detailed diagnosis for every case of cleft. All anatomical regions involved by the cleft are considered and the extent in these regions is described. This nomenclature has been proposed for usage by the Interdisciplinary Cleft Palate and Craniofacial Anomalies Committee of the German Associations for Cranio-Maxillofacial Surgery, Orthodontics, Phoniatrics, Pedaudiology and ENT.

Cleft Lip↗
PubMed2003

Estimating the costs of VA ambulatory care.

This article reports how we matched Common Procedure Terminology (CPT) codes with Medicare payment rates and aggregate Veterans Affairs (VA) budget data to estimate the costs of every VA ambulatory encounter. Converting CPT codes to encounter-level costs was more complex than a simple match of Medicare reimbursements to CPT codes. About 40 percent of the CPT codes used in VA, representing about 20 percent of procedures, did not have a Medicare payment rate and required other cost estimates. Reconciling aggregated estimated costs to the VA budget allocations for outpatient care produced final VA cost estimates that were lower than projected Medicare reimbursements. The methods used to estimate costs for encounters could be replicated for other settings. They are potentially useful for any system that does not generate billing data, when CPT codes are simpler to collect than billing data, or when there is a need to standardize cost estimates across data sources.

Accounting↗