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PubMed2004

Quantifying net staffing costs due to longer-than-average surgical case durations.

BACKGROUND: Anesthesiology departments incur staffing costs that are not covered by revenue because the operating room (OR) time allocation and case scheduling are not done to maximize OR efficiency and because surgical durations are longer than average. The purpose of this article is to demonstrate a method to quantify net anesthesia staffing costs due to longer-than-average surgical durations and evaluate the factors that influence staffing costs. METHODS: Data collected from two anesthesiology departments in academic hospitals for 1 yr included date of surgery, time that patients entered the OR, time that patients exited the OR, surgical service, and the Current Procedural Terminology code for the primary surgical procedure. Anesthesia care performed outside the main surgical suite and services not billed with American Society of Anesthesiologists units were excluded. National average surgical durations were determined from the Current Procedural Terminology code from the Centers for Medicare and Medicaid Services' database. Actual surgical durations were then used to determine staffing solutions to maximize OR efficiency; national average surgical durations were then used to determine a second solution. The difference in staffing costs between these two staffing solutions represented the staffing costs attributable to longer surgical durations. Costs were converted to dollar amounts using compensation values reported in a national compensation survey. The differences in revenue were determined by applying conversion factors to the differences in surgical durations. The annual net cost attributable to longer surgical durations equaled the staffing costs minus the revenue produced by longer durations. Net staffing costs were estimated for two hospitals using median staffing compensation and median payer mix. Net staffing costs were then recalculated by varying the parameters (conversion factors, limits on differences between actual and average surgical duration, levels of compensation, surgical service size of OR allocation). RESULTS: Using the median compensation of staff and an average conversion factor, the net annual staffing costs attributable to longer surgical durations were $672,100 for the first hospital. However, if staff members were highly compensated and the payer mix was unfavorable, the net staffing costs were $1,688,000. Reducing the difference between actual and average duration resulted in lower staffing costs. Net staffing costs were less in a second hospital studied that had many low-volume surgical services. CONCLUSIONS: Longer-than-average surgical durations can increase net staffing costs for anesthesiology groups. The increase is dependent on factors such as staffing compensation and payer mix.

Anesthesia Department, Hospital↗
PubMed2006

Physician documentation essential for accurate coding and billing of excision of skin lesions.

Clear and precise documentation is essential to accurately code and bill for excision of benign or malignant skin lesions. Detailed documentation is crucial for capturing the full allowable reimbursement when the procedure involves more than a simple closure. For each lesion, only one type of removal may be reported, whether it is destruction, debridement, paring, curettement, shaving or excision. If an initial attempt to remove a lesion by a less invasive procedure is immediately followed by a more invasive lesion removal, only the more complex, definitive procedure may be billed. According to the Current Procedure Terminology manual (CPT), an excision of a skin lesion is defined as "full-thickness (through the dermis) removal of a lesion, including margins, and includes simple (non-layered) closure when performed." Changes in recent years now allow code selection based on the greatest clinical diameter of the lesion plus the narrowest margin required for adequately excising the lesion, "based on the physician's judgment." According to CPT, the "measurement of lesion plus margin is made prior to excision".

Current Procedural Terminology↗
PubMed2005

Hitting the mark ... sometimes. Improve the accuracy of CPT code distribution.

Researchers examined the current procedural terminology (CPT) evaluation and management (E&M) code distribution before and after applying corrections for the inaccuracy of code assignment to actual CPT E&M claims. They found that code distribution differed dramatically after the practice's claims were corrected for coding errors identified by coding analysts. Physicians' poor understanding of coding guidelines and regulatory pressure to code correctly may account for the discrepancies. Regardless of the reasons, poor coding opens an organization to compliance audits and loss of legitimately earned revenue.

Current Procedural Terminology↗
PubMed2003

Standardized positioning of patients (poses) for whole body cutaneous photography.

Whole body photography (WBP) has been used for decades by some specialized pigmented lesion clinics as an aid to early melanoma detection in high-risk persons. The recent advent of digital imaging systems for acquiring and archiving whole body skin images has resulted in greater dissemination of this technique. This in turn has led to the recent establishment of a Category III Current Procedural Terminology code for WBP. Here we present a proposed set of standardized body poses for WBP on the basis of the extant literature and the experience of a panel of experts in the field. The proposed poses were developed with consideration of patient comfort and technical efficiency. The poses were optimized to comply with a predetermined set of desirable technical parameters as assessed in a series of 20 consecutive patients. The resulting set of poses is presented as a first step toward the increased standardization of dermatologic WBP.

Current Procedural Terminology↗
PubMed2005

Clinical services provided by interventional radiologists to Medicare beneficiaries in the United States, 2000-2003.

To identify trends in Evaluation and Management (E&M) and non-E&M services of interventional radiologists (physician specialty type 94) from 2000 to 2003 for Medicare patients, Medicare Part B physician annual allowed services data from the Centers of Medicare and Medicaid Services (CMS) were analyzed for all interventional radiologists from 2000 to 2003. Because the number of interventional radiologists in the United States according to the Society of Interventional Radiology is, on average, 4.2 times the number of interventional radiologists who use physician specialty type 94, we extrapolated the E&M services for each year. During the period examined, the total number of E&M services by interventional radiologists increased 309%, from 9,698 in 2000 to 29,914 in 2003. The most commonly performed services were Office or Other Outpatient Visit (Current Procedural Terminology [CPT] codes 99211-99215) for established patients, followed by Subsequent Hospital Care (CPT 99231-99233) and Office or Other Outpatient Consultations (CPT 99241-99245). The extrapolated number of E&M services by interventional radiologists for Medicare patients in 2003 is approximately 107,853. The number of Office and Outpatient Visits for New Patients (CPT 99201-99205) increased 142%, whereas the number of Consultations for New Patients (CPT 99241-99245) increased 208%. The total number of codes reimbursed by CMS to interventional radiologists (type 94) increased from 2.8 million in 2000 to 3.8 million in 2003.

Current Procedural Terminology↗
PubMed2005

CPT coding and reimbursement issues in dermatology.

In the past 6 years, significant changes have been made in Current Procedural Terminology codes, descriptors, and guidelines affecting dermatologists. These changes involved excision, repair, measuring excised diameter, measuring flap defects, skin biopsy and Mohs surgery guidelines, KOH examination, and fungus cultures. New codes were introduced for photodynamic therapy, laser treatment, and whole-body photography. Reimbursement issues affecting dermatologists are also discussed, including inappropriate bundling of separate services, failure to recognize modifiers, and unfair multiple procedure reduction. The successes of the American Academy of Dermatology Association advocacy efforts with insurance carriers are summarized, with an update on the current status of these issues. Physician responsibilities, documentation requirements, and expectations are also outlined.

Current Procedural Terminology↗
PubMed2004

Commentary. Health and behavior CPT codes: an opportunity to revolutionize reimbursement in pediatric psychology.

Recently accepted codes in the Current Procedural Terminology system permit licensed pediatric psychologists to deliver psychological services utilizing billing codes that focus on improving medical and physical health. They potentially allow pediatric psychologists to obtain third-party reimbursement for services within a biopsychosocial model of care without requiring a concurrent psychiatric diagnosis. These codes represent a potential major paradigm shift whereby the services of a pediatric psychologist are provided and billed within the context of physical health care. Information is provided on the history of these codes along with detailed information regarding their utilization. Future directions for implementation, teaching, and research are provided along with a strong encouragement for use of these codes by pediatric psychologists.

Behavior Therapy↗
PubMed2006

Correct coding for laboratory procedures during assisted reproductive technology cycles.

New Current Procedural Terminology (CPT) codes for 2004 have been adopted for utilization with assisted reproductive technologies. It is important for professionals in the field of assisted reproductive technology (ART) to become familiar with them prior to their implementation. This document replaces the July 2002 American Society for Reproductive Medicine (ASRM) Practice Guideline Correct Coding for Laboratory Procedures During Assisted Reproductive Technology.

Clinical Laboratory Techniques↗
PubMed2006

Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record.

OBJECTIVE: The aim of the study was to describe a paper-based, template-driven and an electronic medical record used for capturing emergency care clinical information and to compare the accuracy of these documentation systems for coding patient encounters using the American Medical Association Current Procedural Terminology-2004 (AMA CPT-2004) evaluation and management codes intended for provider reimbursement. METHODS: A retrospective, cross-sectional study of 4-consecutive-day samples of ED patient encounter records from 2 similar community hospitals was done. For clinical documentation, hospital A uses an electronic medical record, whereas hospital B uses a paper-based template-driven record. Using a simple analytic model, expert coders A and B, respectively, coded the records from hospitals A and B for completeness. First, power analysis determined the acceptability of the patient record sample sizes (1 - beta = .90 at 1% significance level), and the frequency of AMA CPT-2004 primary evaluation and management codes 99281 through 99285 was calculated. Second, the completeness discrepancy rates for hospitals A and B were compared to determine the accuracy of both the paper-based, template-driven record and the electronic medical record in documenting and representing the clinical encounter. Third, interrater reliability between expert coders A and B was calculated to assess the level of agreement between each expert coder in determining the completeness discrepancy rates between hospitals A and B. Finally, the frequency of primary evaluation and management codes was analyzed to determine if there was a statistically significant difference between the paper-based, template-driven record and the electronic medical record representation of the clinical information, and if that difference could be attributable to the differing clinical documentation systems used in hospitals A and B. RESULTS: First, descriptive display demonstrated a difference in the frequency of the primary evaluation and management codes 99283 and 99284 within hospital A (expert coder A assessment, 36.1% vs 39.1%; expert coder B assessment, 36.6% vs 38.7%) and hospital B (expert coder A assessment, 47.8% vs 21.9%; expert coder B assessment, 48.6% vs 21.4%) was noted with the median, primary evaluation, and management code for hospital A of 99284 and the median, primary evaluation, and management code for hospital B of 99283. Second, Fisher exact test compared the completeness discrepancy rates between hospitals A and B as assessed by each expert coder and demonstrated no statistically significant difference in the completeness discrepancy rates (accuracy) between the paper-based, template-driven record and the electronic medical record documentation and coding system when assessed by either expert coder A (P = .370) or expert coder B (P = .819). Third, interrater reliability between expert coders A and B was evaluated using Cohen's kappa statistic. When evaluated both individually and jointly with respect to hospitals A and B, expert coders A and B had a good strength of agreement in their assessments of the accuracy of the documentation and coding system for hospital A (kappa = 0.6200) and hospital B (kappa = 0.6906) as well as for both hospitals evaluated together (kappa = 0.6616). Finally, interhospital differences in the frequency of primary evaluation and management codes were evaluated using Pearson chi(2) test with 3 df. The results for expert coder A (chi(2) = 47.4160; P < .001) and expert coder B (chi(2) = 46.5946; P < .001) recognize that there is a statistically significant degree of difference between hospitals A and B in the frequency distribution of primary evaluation and management codes, probably because of the dispersion of codes 99283 and 99284. CONCLUSIONS: A keystroke-driven, electronic medical record that resides on a knowledge platform that incorporates a clinical structured terminology, administrative coding schemata, AMA CPT-2004 codes and uses object-oriented, open-ended, branching chain clinical algorithms that "force" physician documentation of the clinical elements provides an equally accurate capture and representation of ED clinical encounter data as a paper-based, template-driven documentation system both in terms of the presence or absence of both the medically necessary, discrete data elements and the textual documentation-dependent, medical decision-making elements.

Chi-Square Distribution↗
PubMedDate not supplied

Genetic testing coverage and reimbursement: a provider's dilemma.

The rapid growth of new molecular genetic tests stimulated by the diagnostic potential of DNA/RNA analyses has resulted in the capability of molecular genetic assay technology outpacing the American Medical Association Current Procedural Terminology (CPT) codes and Medicare reimbursement. The AMA CPT Editorial Panel is poised to change the way we report genetic testing, and this change may have the potential to stimulate a governmental review of how Medicare is paying for diagnostic genetic testing. Genetic assays are costly, and those in laboratory management need to be aware of potential changes that may influence the ability of their laboratory to provide access to genetic testing services for their physician clientele. The commercialization of genetic testing has resulted in a proliferation of commercial laboratories and university medical center laboratories, CLIA-certified to perform high complexity testing, offering some level of genetic testing. The genetic tests are offered as home brew (in-house developed) assays, most of which are using analyte-specific reagents. Because these are home brew assays, there is no standardization in how the industry tests for specific mutations. As these genetic assays are billed using the generic molecular diagnostic codes, 83890 through 83912, from the Pathology and Laboratory Chemistry subsection of the CPT, payers are not able to identify the specific mutations being tested and make payment determinations based on the mutations as they relate to the diagnosis code. This article discusses the history of molecular diagnostic coding and related reimbursement, current coverage issues, and the genetic coding proposal under consideration by the AMA CPT Editorial Panel.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed2002

Using Medicare data to estimate the prevalence of breast cancer screening in older women: comparison of different methods to identify screening mammograms.

OBJECTIVES: To compare different methods for defining screening mammograms with Medicare claims and their impact on estimates of breast cancer screening rates. METHODS: Medicare outpatient facility and physician claims for 61,962 women in 1993 and 59,652 women in 1998 were reviewed for evidence of receipt of screening mammography. We compared the estimates of screening mammography use derived from CPT (Current Procedure Terminology) codes to categorize mammograms as screening or diagnostic versus using an algorithm that uses CPT codes plus breast-related diagnoses in the prior two years. We also compared estimates obtained from review of physician claims alone, facility claims alone, or the combination of the two sources of claims. RESULTS: Use of physician claims alone produced estimates of screening rates similar to rates calculated from use of both physician and outpatient (facility) claims. In 1993, the CPT code for screening mammography underestimated the rate of screening compared to estimates generated by using the algorithm (8.3 percent versus 18.0 percent prevalence, p<0.001). By 1998, the screening prevalence rate generated from using the CPT code for screening mammography more closely approximated the rate generated by the algorithm (23.0 percent versus 25.1 percent). By all methods of estimating screening mammography with Medicare claims, its prevalence increased substantially between 1993 and 1998. CONCLUSION: Providers increased their use of the screening mammography code in their charges to Medicare during the 1990s. This has improved the claims' ability to distinguish screening from diagnostic mammograms, but screening rates computed with claims continue to fall below those generated from self-reports of mammography use among general populations of older women.

Aged↗
PubMed2006

Insurance barriers for childhood survivors of pediatric brain tumors: the case for neurocognitive evaluations.

OBJECTIVE: The purpose of the present study was to provide empirical evidence of system-based barriers to psychological services for pediatric brain tumor patients when they are medically indicated. METHOD: Insurance claims data covering 263,866 insured lives during the 1996 fiscal year were pooled from a cross-sectional national sample of adults and their families insured by private insurance companies or self-insured firms. Based on inclusion criteria, records for 209 pediatric brain tumor patients aged 18 and under were extracted and analyzed. Claims data including total amount of payments made on behalf of a member, total length of hospital stays, and total number of unique admissions were recorded for all patients, and current procedural terminology (CPT) codes were analyzed to determine frequency of payment for routinely billed psychological procedures. Results were then compared to the frequency of payment for routinely billed psychological procedures for children with other medical conditions. RESULTS: Results indicate that two of the CPT codes commonly associated with neurocognitive evaluations were reimbursed by these third-party payers for pediatric brain tumor patients during the 1996 fiscal year. Additionally, seven of the CPT codes commonly associated with psychological therapy were also reimbursed. CONCLUSIONS: The present findings provide empirical evidence of system-based obstacles (i.e., lack of third-party reimbursement) for medically indicated psychological services in pediatric brain tumor patients.

Brain Neoplasms↗
PubMed2003

National Academy of Neuropsychology/Division 40 of the American Psychological Association Practice Survey of Clinical Neuropsychology in the United States. Part II: Reimbursement experiences, practice economics, billing practices, and incomes.

Leaders of the National Academy of Neuropsychology and Division 40 (Clinical Neuropsychology) of the American Psychological Association determined that current information on the professional practice of clinical neuropsychology within the United States was needed. These two organizations co-sponsored a national survey of U.S. clinical neuropsychologists that was conducted in September 2000. The primary goal of the survey was to gather information on such topics as: practitioner and practice characteristics, economic variables (e.g., experience with major third party payors, such as Medicare and managed care), practice expenses, billing methods, experiences with Current Procedural Terminology (CPT) codes, time spent on various clinical tasks, use of assistants, and income. In this second of two articles describing the survey results, reimbursement experiences, practice economics, billing practices, and incomes are highlighted. Survey results indicate that neuropsychologists frequently have difficulty gaining access to membership on managed care panels. For those who gain access, managed care companies often limit provision of services; this is quite often perceived as negatively affecting quality of patient care. It is very common for neuropsychologists to feel obligated to provide more services to managed care and Medicare patients than are allowed to be billed to the insurance carrier; these hours are typically "written off." Numerous CPT codes are used to bill the same clinical service. Awareness of Medicare practice and billing expectations is variable among practitioners, as is awareness of public aid/Medicaid billing status. Professional income is influenced by years of licensed practice, practice setting, gender, types and amounts of non-clinical professional activities, and types and amounts of reimbursement sources within one's clinical practice. Income of neuropsychologists has only a minimal relationship to percentage of clinical practice per week. Within the context of prior surveys, neuropsychologists are engaging in more clinical hours per week and, nevertheless, compared to data from 1993, are reporting decreased income. These and other findings are presented and discussed.

Academies and Institutes↗
PubMed2006

Frequently asked coding questions.

Current Procedural Terminology (CPT) coding is not an exact science. Although the CPT code set was developed to describe clearly and comprehensively services provided by health care professionals, the intended application of individual codes is not always clear. In addition, coding that may be correct in terms of CPT definitions and instructions may contradict instructions from payment policies set by insurers. This article provides answers to the gastroenterologists' most commonly asked questions and provides primary sources for coding and payment policies when possible. Answers to the questions are accurate as of the date of publication but may be subject to change.

Biopsy↗
PubMed2006

Regulatory changes that affect coding for immunotherapy.

BACKGROUND: During the past decade, a variety of federal regulations have had a significant impact on the way allergen immunotherapy is reimbursed and how Current Procedural Terminology (CPT) codes are used for this purpose. As mandated by the US Congress, the Centers for Medicare and Medicaid Services (CMS) through the Office of the Inspector General (OIG) targeted immunotherapy codes for scrutiny, because they are some of the most frequently used codes. OBJECTIVE: To examine how federal regulations have affected reimbursement for allergy immunotherapy and other allergy services. METHODS: A review was performed of the OIG survey of allergy immunotherapy and the OIG recommendations on CPT coding compliance guidelines. RESULTS: A preliminary survey found problems with medical appropriateness of allergen immunotherapy. For this reason, the OIG performed a more comprehensive study of 301 physicians using code 95165 to analyze by medical record and billing data whether the new billing rules were being correctly used and found that only 44% of physicians were following the new definition of a billable dose. In the early 1990s, the federal government served notice of its intent to more aggressively identify and prosecute health care providers who improperly billed and collected for medical services. Through the adoption of the 1991 US Sentencing Commission Guidelines, the government sought to enhance compliance by mandating lesser criminal penalties for violating organizations that nevertheless maintained and operated "effective compliance plans." In 2002, the OIG audited health care providers and recouped dollar 14.4 billion in improper payments by Medicare. Between January and June 2003, Medicare excluded 1,241 individual providers and health care entities due to fraudulent billing practices. CONCLUSIONS: Federal regulations have significantly affected reimbursement for allergy immunotherapy and other allergy services. Allergists need to be aware of these changes and implement the new recommendations into their practices.

Aged↗
PubMed2005

Understand the "fine print" when selecting the correct codes for patient admissions from clinic to hospital.

How should a physician code and bill for services when a patient is seen in the clinic and then is directly admitted to the hospital? The correct answer is not as straightforward as it might at first seem because of needing to understand what amounts to the "fine print" in the Current Procedural Terminology (CPT) book code description. It also depends on whether or not the physician subsequently had face-to-face contact with the patient in the hospital. According to the CPT book, "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g. physician's office) all evaluation and management services (E/M) provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission. The inpatient care level of service reported by the admitting physician should include the services related to the admission s/he provided in the other sites of service as well as in the inpatient setting." At first, this wording could lead physicians and coders to conclude that their only recourse is to "roll up" the level of service provided in the clinic with the additional documentation necessary to admit a patient to the hospital to determine the code for "Initial Hospital Care", CPT 99221-99223. However, it has been noted that the description in the CPT book under initial hospital care has "fine print" in the statement the "codes are used to report the first hospital inpatient encounter with the patient by the admitting physician." "Encounter" is commonly understood to mean a "face to face" encounter between the physician and patient in the hospital setting. But, what if the physician does not go to the hospital to see the patient on the same date that s/he saw the patient in the clinic? Because a face to face encounter in the hospital did not occur, it would be inappropriate to use any of the "Initial Hospital Care" CPT 99221-99223 codes. Rather, the services of the clinic visit should be billed as "new" or "established" patient office visit on the date seen and the initial hospital service would be billed on a following date when the physician actually sees the patient in the hospital setting.

Ambulatory Care Facilities↗
PubMed2005

A mobile trauma database with charge capture.

BACKGROUND: Charge capture plays an important role in every surgical practice. We have developed and merged a custom mobile database (DB) system with our trauma registry (TRACS), to better understand our billing methods, revenue generators, and areas for improved revenue capture. METHODS: The mobile database runs on handheld devices using the Windows Compact Edition platform. The front end was written in C# and the back end is SQL. The mobile database operates as a thick client; it includes active and inactive patient lists, billing screens, hot pick lists, and Current Procedural Terminology and International Classification of Diseases, Ninth Revision code sets. Microsoft Information Internet Server provides secure data transaction services between the back ends stored on each device. Traditional, hand written billing information for three of five adult trauma surgeons was averaged over a 5-month period. Electronic billing information was then collected over a 3-month period using handheld devices and the subject software application. One surgeon used the software for all 3 months, and two surgeons used it for the latter 2 months of the electronic data collection period. This electronic billing information was combined with TRACS data to determine the clinical characteristics of the trauma patients who were and were not captured using the mobile database. RESULTS: Total charges increased by 135%, 148%, and 228% for each of the three trauma surgeons who used the mobile DB application. The majority of additional charges were for evaluation and management services. Patients who were captured and billed at the point of care using the mobile DB had higher Injury Severity Scores, were more likely to undergo an operative procedure, and had longer lengths of stay compared with those who were not captured. CONCLUSION: Total charges more than doubled using a mobile database to bill at the point of care. A subsequent comparison of TRACS data with billing information revealed a large amount of uncaptured patient revenue. Greater familiarity and broader use of mobile database technology holds the potential for even greater revenue capture.

Accounting↗