Dollars and sense: revenue opportunities in home care medicine.
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Current Procedural Terminology↗
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Opportunities for advance practice nurses in the nursing facility.
Advance practice nurses (APNs) have emerged as valuable members of the nursing facility interdisciplinary team. They function in a variety of roles, including clinical care, administration, nursing consultation, and education. Positive outcomes in key indicators of care and reduction in costs to the healthcare systems have been attributed to their practice. Barriers to implementation of the role include regulatory issues, facility resistance, and difficulty adapting to the environment. Facilitation of the role is enhanced by collegial relationships and role negotiation. There is strength in the APN-physician collaborative model. The APN is likely to concentrate on prevention, restoration, maintenance, and palliative care, allowing the physician to concentrate on complex medical problems. There is a need for APN practices to identify APN-sensitive outcomes, collect and analyze data, and disseminate findings.
Certification↗
Validity of procedure codes in International Classification of Diseases, 9th revision, clinical modification administrative data.
BACKGROUND: Administrative hospital discharge data are widely used to assess quality of care in patients undergoing certain procedures. However, little is known about the validity of administrative coding of procedure data. We conducted a detailed chart review to evaluate the accuracy and completeness of information on procedures in administrative data. METHODS: We randomly selected 1200 hospital separations in the period April 1, 1996, to March 31, 1997, from administrative discharge data of 3 acute adult hospitals in Calgary, Alberta, Canada. Each separation record in administrative data contains up to 10 procedure coding fields. The corresponding medical charts were reviewed for recording presence or absence of procedures. We then determined sensitivity to quantify the accuracy of coding presence of procedures in administrative data when these are present in the chart data (criterion standard). RESULTS: The agreement between the 2 databases varied greatly across 35 procedures studied. The sensitivity ranged from 0% to 94%. Of 6 major procedures studied, validity of coding was generally good, with 5 procedures having coding sensitivity of 69% and over and only 1 (lysis of peritoneal adhesion) with a low sensitivity of 41%. In contrast, many minor procedures had low sensitivities. Of 29 minor procedures studied, sensitivity was lower than 50% for 15 procedures, between 50% and 79% for 10, and 80% and over for 4. CONCLUSION: Validity of information on procedures in administrative discharge data appears to be related to type of procedures. Major procedures that are usually performed in operating rooms are reasonably well-coded. Meanwhile, minor procedures that are routinely performed on wards or in radiology departments are generally undercoded.
Alberta↗
Quality of diagnosis and procedure coding in ICD-10 administrative data.
OBJECTIVES: The International Classification of Disease, 10th Revision (ICD-10) was introduced worldwide beginning in the late 1990s. Because there have been no published data on the quality of coding using ICD-10, the aim of our analysis is to assess the quality of ICD-10 coding in routinely collected hospital discharge data from Australia, which began using ICD-10 in 1998. METHODS: Audit data from the years 1998-1999 (n = 7004) and 2000-2001 (n = 7631), excluding same-day chemotherapy and dialysis cases, were used in data analysis. Quality measures included prevalence comparisons, sensitivity, positive predictive value (PPV), and the kappa statistic. RESULTS: Comparison of the audit sample to public hospital discharges showed little difference in age and gender, with audited cases more likely to be overnight stays. There was no difference in the median number of hospital assigned diagnosis and procedure codes per discharge. Agreement of the principal diagnosis code was 85% at the 3-digit level and 79% at the 4-digit level in 1998-1999; this rate had improved to 87% and 81% in 2000-2001. Principal procedure code agreement was 85% in 1998-1999 and 83% in 2000-2001 at the 5-digit level, and 81% and 80% at the 7-digit level, respectively. Specific major diagnoses, comorbid diagnoses, major procedures, and minor procedures showed good-to-excellent coding quality. CONCLUSIONS: The transition to ICD-10 has occurred with no loss of data quality, with data showing a high level of reliability and adherence to coding standards. When consideration is given to the nature of the analysis, administrative data can provide highly reliable population-based estimates of hospitalization rates.
Adult↗
Survey of academic pediatric emergency departments regarding use of evaluation and management codes.
OBJECTIVE: The aims of the study were to determine the frequency at which each emergency medicine evaluation and management (E/M) code is used, to identify factors associated with their use by academic pediatric emergency departments (PEDs), and to compare PED E/M code utilization rates with rates reported by Centers for Medicare and Medicaid Services for general emergency departments (EDs). METHOD: A 24-question survey was sent to 42 academic PED medical directors. Questions pertained to PED demographics, physician staff, records/documentation, billing education, and E/M coding data for 1 year. The general ED E/M code utilization rates were obtained from the published Centers for Medicare and Medicaid Services database. Descriptive statistics and odds ratios were used to report and compare the data. RESULTS: Twenty (48%) of the surveys were returned, and 9 (21%) completed the E/M coding data questions. From these 9 departments, the mean PED annual census was 46,065 (range, 23,531-92,910). The methods of PED medical record documentation were template (6), handwritten (2), and dictation/transcription (1). Charge documents were completed by the PED physician (3), professional service coders (4), and hospital coders (2). Coding/documentation in-services were provided to the physicians of 7 PEDs, and billing audits were performed in 5 PEDs. The total number of charges for the 9 PEDs was 325,129, 78.4% of the census. Multiple reasons were given for the discrepancy between census and charges. The percentage of each of the 5 levels of service billed was calculated for each of the 9 PEDs. The 2 lowest levels of service were used 38.3% of the time, whereas the 2 highest were used 19.2% of the time. The range for the highest level of service varied widely from 5.3% to 53.3%. Approximately 65% of E/M codes used by general EDs were for the 2 highest levels of service. The PED with the highest percentage of upper level charges (53.4%) was the only PED that used dictation/transcription for documentation. CONCLUSION: Although the response rate was low, and thus the validity of the results was limited, the findings may serve as a benchmark for E/M code utilization in PEDs. The large variation in use of the E/M codes among the PED in our study and the lower rate of using the highest E/M codes by the PEDs compared with the general EDs suggest potential opportunities for academic PEDs to improve billing practices.
Academic Medical Centers↗
Practicing surgeons lead in quality care, safety, and cost control.
OBJECTIVE: To report the experiences of 66 surgical specialists from 15 different hospitals who performed 43 CPT-based procedures more than 16,000 times. SUMMARY BACKGROUND DATA: Surgeons are under increasing pressure to demonstrate patient safety data as quantitated by objective and subjective outcomes that meet or exceed the standards of benchmark institutions or databases. METHODS: Data from 66 surgical specialists on 43 CPT-based procedures were accessioned over a 4-year period. The hospitals vary from a small 30-bed hospital to large teaching hospitals. All reported deaths and complications were verified from hospital and office records and compared with benchmarks. RESULTS: Over a 4-year inclusive period (1999-2002), 16,028 elective operations were accessioned. There was a total 1.4% complication rate and 0.05% death rate. A system has been developed for tracking outcomes. A wide range of improvements have been identified. These include the following: 1) improved classification of indications for systemic prophylactic antibiotic use and reduction in the variety of drugs used, 2) shortened length of stay for standard procedures in different surgical specialties, 3) adherence to strict indicators for selected operative procedures, 4) less use of costly diagnostic procedures, 5) decreased use of expensive home health services, 6) decreased use of very expensive drugs, 7) identification of the unnecessary expense of disposable laparoscopic devices, 8) development of a method to compare a one-surgeon hospital with his peers, and 9) development of unique protocols for interaction of anesthesia and surgery. The system also provides a very good basis for confirmation of patient safety and improvement therein. CONCLUSIONS: Since 1998, Quality Surgical Solutions, PLLC, has developed simple physician-authored protocols for delivering high-quality and cost-effective surgery that measure up to benchmark institutions. We have discovered wide areas for improvements in surgery by adherence to simple protocols, minimizing death and complications and clarifying cost issues.
Adult↗
Medicare's bundling of trauma care codes violates relative value principles.
BACKGROUND: Physician payment by Medicare is based on a Resource-Based Relative Value Scale (RBRVS). The Correct Coding Initiative (CCI) was introduced to counter unbundling by pairing component procedures with more comprehensive procedures. We hypothesized that Medicare's rebundling process ignored relative value concepts. METHODS: CCI tables were downloaded from Medicare's website. Each comprehensive code's Relative Value Units (RVUs) were compared with component RVUs. Trauma, Burn, and Critical Care (TBC) surgeon charges were analyzed to determine whether component services had higher RVUs than the comprehensive charge. RESULTS: 2,990 component CPT codes had total RVUs exceeding the RVUs of their paired comprehensive codes. If the undervalued comprehensive codes had been valued at their highest component's value, the minimum additional revenue would have been $211,600.59 per surgeon per year. CONCLUSION: A relative value scale depends upon equity in value units. Disregarding RVUs when bundling services and procedures results in severe physician underpayment.
Current Procedural Terminology↗
One little lesion--so many choices: part 2 of 2: The diagnosis aspect and more CPT notes.
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Breast Neoplasms↗
The impact of managed eye care on use of vision services, vision costs, and patient satisfaction.
OBJECTIVES: This study was designed to evaluate the impact of introducing a managed vision benefit program on the use and costs of vision services in a managed care setting and also to assess satisfaction with those services after the program was introduced. METHODS: Utilization and costs were compared for two groups of patients. The comparison group (n = 36,168) included all patients enrolled for 18 months before implementation of the managed eye-care plan. The study group (n = 23,816) included those enrolled for 18 months following its implementation. Medical claims, survey, and administrative data were used to evaluate study outcomes. RESULTS: The overall use of vision care was similar before and after the introduction of the managed eye-care programs, with 24% of each group receiving at least one vision service during the 18-month period. Nevertheless, an increase in the use of routine eye-care services and a decrease in medical eye-care services were observed following program implementation. The overall cost of providing eye-care services to patients decreased from 1.86 dollars to 1.36 dollars per member per month after the program started, largely owing to a reduction in spending associated with medical eye-care services. More than 90% of patients surveyed were satisfied with their vision care provided by the program. CONCLUSIONS: Findings suggest that introducing routine and medical managed eye-care programs in a managed care setting allows for a reduction in medical costs while maintaining access to care and patient satisfaction.
Adult↗
Validating CPT typical times for Medicare office evaluation and management (E/M) services.
Every 5 years, the federal government reviews the Medicare Fee Schedule for changes in the work effort physicians personally devote to office visits. Using physician face-to-face times reported in the Centers for Disease Control and Prevention's National Ambulatory Care Survey (NAMCS), guideline office visit times associated with the 1997-1998 mix of Medicare claims averaged 9 percent longer versus NAMCS; Medicare billed visits with new patients were 32 percent longer. Surgeons and dermatologists had the largest discrepancies in Medicare versus NAMCS times. If CPT guideline times currently in use are now overstated, then intraservice work effort is likely overstated given the high correlation of time with work effort, and Medicare payment levels need to be reduced. Upcoding visit content to higher paid CPT visit codes may also explain seemingly longer Medicare billed times and call for payment reductions as well.
Current Procedural Terminology↗
Validation of physician survey estimates of surgical time using operating room logs.
The Medicare Physician Fee Schedule (MFS) is based on relative value units that represent the costliness of a particular service compared to all other services. Comparison of current surgical time estimates show systematically longer times than those obtained in the original Harvard study more than a decade ago. Any bias in surgical time estimates is likely to distort MFS payments across specialties. This study is the first to use objectively collected intraservice surgical time to validate estimates of time collected from small-group physician surveys. Median intraservice time estimates are significantly longer than intraservice times from operative logs. The average difference across 60 procedures is 31 minutes; the range is from a few minutes to almost 2 hours. Given that half of the studied surgical procedures is a subset of services that anchors the MFS, surgical times for other related services are likely to be overstated as well.
Centers for Medicare and Medicaid Services, U.S.↗
A cross sectional survey of urban Canadian family physicians' provision of minor office procedures.
BACKGROUND: A discordance exists between the proportion of Canadian family physicians that we expect should be able to perform minor office procedures and the actual provision of care. This pattern has not been extensively studied. The objective of this study was to determine the current patterns and obstacles relating to the provision of four minor office procedures by GP/FPs in a small city in Ontario, Canada. An additional goal was to determine the impact of the remuneration method on the provision of such services. METHODS: A survey was mailed to all GP/FPs practising in Kingston, Ontario. The main outcomes measured in the study were work setting and remuneration method, current procedural practices with respect to four procedures, reasons for not performing procedures, current skill levels, and desire to upgrade. RESULTS: Surveys were mailed to all 108 GP/FPs in the City of Kingston. Completed surveys were collected for 82 percent (89/108) and 10 were excluded leaving 79 eligible participants. The percentages of GP/FPs who reported performing the procedure were as follows: dermatological excision (63.3%), endometrial biopsy (35.4%), shoulder injection (31.6%), and knee injection (43.0%). The majority of GP/FPs who would not do the procedure themselves would refer to a specialist colleague rather than to another GP/FP. The top reason cited for not performing a specific procedure was "lack of up to date skills" followed by "lack of time". The latter was the only statistically significant difference reported between GP/FPs working in Family Health Networks and GP/FPs working in fee for service settings (26.7% vs 47.0%, chi2 = 4.191 p = 0.041). CONCLUSION: A large number of Kingston, Ontario GP/FPs refer patients who require one of four minor office-based procedures for specialist consultation. Referral to other GP/FP colleagues appears underutilized. A perceived lack of up to date skills and a lack of time appear to be concerns. GP/FPs working in Family Health Networks were more likely to perform these procedures themselves. Further studies would clarify the role of changes in medical education, the role of continuing education, and the impact of different remuneration models.
Biopsy↗
Changes in the use of coronary artery revascularization procedures in the Department of Veterans Affairs, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample, 1991-1999.
BACKGROUND: There have been dramatic increases in the number of coronary artery bypass surgeries (CABS) and percutaneous coronary interventions (PCI) performed during the last decade. Whether this finding is true for revascularization procedures performed in Department of Veterans Affairs (VA) medical centers is the subject of this paper. METHODS: This study compared the number of revascularization procedures and rates of use in the VA, the National Hospital Discharge Survey, and the Nationwide Inpatient Sample. Included were men who underwent isolated CABS and/or PCI, including stenting, between 1991 and 1999, although data for the Nationwide Inpatient Sample were available only between 1993 and 1997. Age adjusted use rates were calculated with the direct method of standardization. RESULTS: The percent of users of VA healthcare 75 years and older increased from 10% in 1991 to 20% in 1999. In the VA, the number of isolated CABS declined from 6227 in 1991 to 6147 in 1999, whereas age adjusted rates declined from 167.6 per 100,000 in 1991 to 107.9 per 100,000 in 1999. In the 2 national surveys, both the estimated numbers of procedures and use rates increased over time. In all 3 settings, there were increases in both numbers and rate of PCI from 1993, although in the VA, use rates decreased from 191.2 per 100,000 in 1996 to 139.7 per 100,000 in 1999. VA use rates for both CABS and PCI were lower than those in the 2 national surveys. CONCLUSION: Age adjusted rates of CABS and PCI were lower in the VA than in 2 national surveys. Since 1996, there has been a decrease in the rate of use of revascularization procedures in the VA.
Adult↗
The Surgical Nosology In Primary-care Settings (SNIPS): a simple bridging classification for the interface between primary and specialist care.
BACKGROUND: The interface between primary care and specialist medical services is an important domain for health services research and policy. Of particular concern is optimising specialist services and the organisation of the specialist workforce to meet the needs and demands for specialist care, particularly those generated by referral from primary care. However, differences in the disease classification and reporting of the work of primary and specialist surgical sectors hamper such research. This paper describes the development of a bridging classification for use in the study of potential surgical problems in primary care settings, and for classifying referrals to surgical specialties. METHODS: A three stage process was undertaken, which involved: (1) defining the categories of surgical disorders from a specialist perspective that were relevant to the specialist-primary care interface; (2) classifying the 'terms' in the International Classification of Primary Care Version 2-Plus (ICPC-2 Plus) to the surgical categories; and (3) using referral data from 303,000 patient encounters in the BEACH study of general practice activity in Australia to define a core set of surgical conditions. Inclusion of terms was based on the probability of specialist referral of patients with such problems, and specialists' perception that they constitute part of normal surgical practice. RESULTS: A four-level hierarchy was developed, containing 8, 27 and 79 categories in the first, second and third levels, respectively. These categories classified 2050 ICPC-2 Plus terms that constituted the fourth level, and which covered the spectrum of problems that were managed in primary care and referred to surgical specialists. CONCLUSION: Our method of classifying terms from a primary care classification system to categories delineated by specialists should be applicable to research addressing the interface between primary and specialist care. By describing the process and putting the bridging classification system in the public domain, we invite comment and application in other settings where similar problems might be faced.
Australia↗
A methodology to estimate the potential to move inpatient to one day surgery.
BACKGROUND: The proportion of surgery performed as a day case varies greatly between countries. Low rates suggest a large growth potential in many countries. Measuring the potential development of one day surgery should be grounded on a comprehensive list of eligible procedures, based on a priori criteria, independent of local practices. We propose an algorithmic method, using only routinely available hospital data to identify surgical hospitalizations that could have been performed as one day treatment. METHODS: Moving inpatient surgery to one day surgery was considered feasible if at least one surgical intervention was eligible for one day surgery and if none of the following criteria were present: intervention or affection requiring an inpatient stay, patient transferred or died, and length of stay greater than four days. The eligibility of a procedure to be treated as a day case was mainly established on three a priori criteria: surgical access (endoscopic or not), the invasiveness of the procedure and the size of the operated organ. Few overrides of these criteria occurred when procedures were associated with risk of immediate complications, slow physiological recovery or pain treatment requiring hospital infrastructure. The algorithm was applied to a random sample of one million inpatient US stays and more than 600 thousand Swiss inpatient stays, in the year 2002. RESULTS: The validity of our method was demonstrated by the few discrepancies between the a priori criteria based list of eligible procedures, and a state list used for reimbursement purposes, the low proportion of hospitalizations eligible for one day care found in the US sample (4.9 versus 19.4% in the Swiss sample), and the distribution of the elective procedures found eligible in Swiss hospitals, well supported by the literature. There were large variations of the proportion of candidates for one day surgery among elective surgical hospitalizations between Swiss hospitals (3 to 45.3%). CONCLUSION: The proposed approach allows the monitoring of the proportion of inpatient stay candidates for one day surgery. It could be used for infrastructure planning, resources negotiation and the surveillance of appropriate resource utilization.
Algorithms↗
Patterns of care in early-stage breast cancer survivors in the first year after cessation of active treatment.
PURPOSE: Patterns of health care use have not been well described for breast cancer survivors. The purpose of this study was to describe the health service use in a survivor cohort. PATIENTS AND METHODS: Women with stage I or II breast cancer were recruited (n = 558) after primary treatment for a multicenter, randomized trial of psychoeducational interventions for facilitating transition to survivorship; 418 women completed the study. Participants completed calendar diaries detailing health care use for 1 year after treatment. Services were coded using Current Procedural Terminology-Fourth Edition codes; costs were estimated using year 2000 Medicare reimbursements. RESULTS: Health care use diary data were available for 391 women (70% of the sample). On average, these survivors reported 30 episodes of health service use in the year after treatment. Total annual costs of care averaged more than 1,800 dollars per survivor; medical office visits were the major component of costs. Type of cancer treatment, depression, and physical function and comorbid illness were independent predictors of the costs of services. There were geographic variations in initial local treatment patterns and in post-treatment costs. Notably, all women should have received surveillance mammography in the time period, but only 61.9% did so; the odds of mammogram receipt were higher for women who had a lumpectomy (v mastectomy) and women who were white (v nonwhite). CONCLUSION: Use of health services is frequent and intensive in the first year after treatment for breast cancer. Despite frequent contact with the health care system, there is room for improvement in providing guideline-suggested surveillance mammography for survivors.
Adult↗
Will a "G" PS clarify the landscape?
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Anesthesiology↗
Implementation of the diagnosis procedure combination in specific-function hospitals.
A Nobel medical payment system, the Diagnosis Procedure Combination (DPC), was implemented in Nippon Medical School Hospital and 81 other specific-function hospitals in 2003. This payment system depends on the length of hospital stay and diagnosis and medical procedures, and differs from the existing payment system, which depends on a piece rate. The daily payment differs for among almost 2,500 groups of DPC defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), and procedures, such as operations (K and J codes of the existing payment system). One of the most important outcomes may be a decrease in lengths of hospital stay, because the range of mean lengths of stay in specific-function hospitals has been officially stated to be 14 to 30 days, and the difference between the longest and shortest mean is almost double. The new medical payment system should stimulate competition among hospitals. In order to decrease the length of stay, we developed clinical pathways for patients undergoing surgery, such as laparoscopic cholecystectomy, gastrectomy, and inguinal hernia operations, as well as clinical protocols for the surgical procedures, such as percutaneous transhepatic cholangiodrainage (PTCD) and percutaneous endoscopic gastrostomy (PEG). Health care is undergoing a challenging transition, and we must improve patient care and clinical practice.
Critical Pathways↗