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BACKGROUND Dermatologists specialize in treating conditions of the skin, hair, and nails; however, it is our experience that the field of nail diseases is the least discussed facet of dermatology. Even less acknowledged is the complexity of nail procedures and how best to accurately code for these procedures. OBJECTIVE To convene a panel of experts in nail disease to reach consensus on the most accurate and appropriate Current Procedural Terminology (CPT) codes associated with the most commonly performed nail procedures. METHODS A questionnaire including 9 of the most commonly performed nail procedures and potential CPT codes was sent to experts in the treatment of nail disease, defined as those clinicians running a nail subspecialty clinic and performing nail procedures with regularity. A conference call was convened to discuss survey results. RESULTS Unanimous consensus was reached on the appropriate CPT codes associated with all discussed procedures. LIMITATIONS Although this article details the most commonly performed nail procedures, many were excluded and billing for these procedures continues to be largely subjective. This article is meant to serve as a guide for clinicians but should not be impervious to interpretation in specific clinical situations. CONCLUSION Billing of nail procedures remains a practice gap within our field. The authors hope that the expert consensus on the most appropriate CPT codes associated with commonly performed nail procedures will aid clinicians as they diagnose and treat disorders of the nail unit and encourage accurate and complete billing practices.

Background Prior studies have found rates of emergency department (ED) visits after bariatric surgery approach 15% with the majority (>60%) not requiring admission. The timeframe for which ED utilization remains elevated postoperatively remains unknown. We hypothesize that ED utilization following bariatric surgery remains elevated for months after surgery with the majority of visits not requiring admission. Objective No study has determined the impact bariatric surgery has on health care resource utilization in the two years following surgery. The aim of this study is to determine the frequency of ED visitation in the 2 years following bariatric surgery. Settings Database study, single state-wide insurance database. Methods We queried the Colorado All Payers Claim Database. Patients with data 1 year before and 2 years after surgery were included. Primary outcomes of interest were ED visits or readmissions during the 2-year period. Bariatric surgeries were identified using CPT codes. Diagnoses for an ED visit or readmission were determined by ICD codes. Results A total of 5399 patients underwent bariatric surgery from January 2013–November 2017. Of these, 59% underwent sleeve gastrectomy, 38% Roux-en-Y, 2% gastric band, and 1% another surgery. Median age was 44 (IQR 35–54) years, and 82% were female. Overall, 3103 patients (57%) visited the ED at least once with a total of 12,988 visits, 1267 of which (9.8%) resulted in admission. ED use was highest in the 30 days following surgery (17%) but remained above presurgery baseline for 8 months (7.4% at 8 mo compared with baseline mean 6.4% [95% CI 6.0%–6.8%]). Conclusions ED visits remain elevated for 8 months post bariatric surgery with over 90% of visits not requiring an admission. Interventions that prevent emergency department utilization should be key focus of quality improvement projects to limit health care resource utilization following bariatric surgery.

Background Malleable [MPP] and inflatable [IPP] penile prosthesis surgery for the management of erectile dysfunction is a reliable treatment option with high success rates and excellent patient satisfaction; however, Medicaid coverage transparency is poor leaving a knowledge gap in this population. Aim The present study seeks to assess Medicaid coverage for MPP and IPP by state as evidenced by inclusion in publicly available physician fee schedules. Methods State Medicaid websites were utilized to access public physician fee schedules. Individual search queries were performed for CPT codes 54400 and 54405 which represent insertion of MPP and IPP, respectively. Data were recorded for each device, including the coverage status, physician fees, and the presence of clear documentation of a prior authorization requirement. Outcomes Medicaid physician fee schedules were accessible for 49 out of 50 US states, and 28 states reported coverage for at least one type of penile prosthesis. RESULTS Two states reported coverage for MPP only, one state reported coverage for IPP only, and 24 states reported coverage for both devices. One state reported that it did not cover either device, but listed coverage for a self-contained IPP (CPT 54401) only. Mean physician reimbursement was $477.15 (290.82–$1175.50) for MPP placement and $691.76 (421.68–$1794.27) for IPP. Eleven states documented prior authorization requirements within their fee schedules, while the remaining 17 states did not. Criteria for approval for prior authorization were not clearly stated in any fee schedule. Clinical Implications Efforts to clearly document approval criteria and educate Men’s Health providers on available coverage could result in a significant improvement in sexual satisfaction in the Medicaid population. Strengths and Limitations Graphical representation of states offering Medicaid penile prosthetic coverage and physician reimbursement ranges are provided with comparison to Medicare rates. Limitations include heterogeneity in fee schedules, lack of prior authorization requirement details, inability to correlate to successful claims data, and the evolving nature of Medicaid coverage for the given procedures. CONCLUSIONS Medicaid coverage exists for penile prosthetic surgery in 28 states, although often with significant, non-transparent prior authorization criteria.

Surgeon providers and billing professionals use Current Procedural Terminology (CPT) codes to specify patient treatment and associated charges. In the present study, coding discrepancies between surgeons' first pass coding and employed coders' final codes were investigated. A total of 500 patients over 3 months were retrospectively analyzed for coding discrepancies. To quantify the impact of change, codes with the most accumulated discrepancies were studied and change to annual relative value unit (RVU) was determined. Final submission of codes to billing demonstrated a 161% increase in total codes by the professional coders, versus original surgeon-derived codes (1594 vs 987 CPT codes). The most common source of change between the surgeon and coder was the addition of distinct codes by the billing professional (270 patients, 54.51%). These results demonstrate the existence of coding discrepancies. Future investigation will evaluate the communication between surgeons and billing professionals.

Introduction We evaluated the effect of an operative coaching (OC) model on general surgery chief residents’ operative efficiency (OE) measured by operative times. We hypothesized that higher levels of entrustment surgeons intend to offer resident in future similar cases are associated with improved OE. Materials and Methods From July 2018 to June 2019, we used a validated instrument to score prospective resident entrustment in 228 evaluations of 6 chief residents during 12 OC sessions each (3 lap colectomy, 3 lap cholecystectomy, 3 ventral hernia, 3 inguinal hernia). Operative times of matched case CPT codes performed by coached chiefs (N = 500) were matched via CPT code to the cases of uncoached chiefs in the academic year 2016-2017 (N = 478). Statistical analysis was performed using Pearson correlation and one-way ANOVA. Results Prospective entrustment scores from coached chief residents were associated with significantly shorter operative times in matched complex cases (CC) (r = −0.58, p = 0.0047). A similar trend was observed in noncomplex cases (NCC) (r = −0.29, p = 0.18). Compared to the historical cohort, coached chief residents showed a decrease in mean operative time during complex cases (p = 0.0008, d = 0.44), but an increase in mean operative times for noncomplex cases (p Conclusions An OC model improves chief residents’ prospective entrustment leading to increased OE in cases with greater levels of operative complexity, showing a decrease in mean operative time compared to uncoached residents in certain procedures. This is the first report showing formal coaching may be a method to enhance chief resident OE.

Once a common bariatric procedure, laparoscopic adjustable gastric band (LAGB) is more frequently the subject of conversion procedures, particularly to laparoscopic sleeve gastrectomy (LSG), due to failure of weight loss, weight regain, and band intolerance. Staple line reinforcement (SLR) in primary LSG has been studied extensively, but has not been evaluated in revision procedures. The aim of this study is to investigate commonly used SLR techniques and their effects on morbidity and mortality in single-stage bands converted to sleeves. The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) Participant Use Data Files (PUF) for 2015–2016 were utilized to assess data for single-stage bands converted to sleeves based on CPT codes, and records were stratified by technique of staple line reinforcement. The database contained all the defined variables utilized for analysis with the exception of leak rate and overall morbidity, which had to be derived. Thirty-day outcomes were analyzed using multiple bivariate analyses and Bonferroni corrections were applied. Of the 6,286 patients who underwent single-stage bands converted to sleeves for whom SLR data is available, 56.9% of surgeons utilized SLR only, 21.3% chose no reinforcement technique (No SLR), 13.4% chose SLR plus over-sewing of the staple line (SLR+OSL), and 8.4% chose OSL alone. There were no statistically significant differences in rates of death, reoperation, readmission, reintervention, number of bleeding events, and staple line leaks across groups. Choice of SLR does not affect number of bleeding events or staple line leak rate.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes. SUMMARY Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

Relative value units (RVUs) are the measure of value used in United States Medicare and Medicaid reimbursement. The Relative Update Committee (RUC) determines physician work RVU (wRVUs) based on operative time, technical skill and effort, mental effort and judgment, and stress. The primary aim of this study was to assess whether operative time is adequately accounted for in the wRVU system in pediatric urology.The American College of Surgeons National Surgical Quality Improvement Program Pediatric Participant User File (ACS-NSQIPP-PUF) was reviewed from 2012 to 2017. Most common single pediatric urology current procedural terminology (CPT) codes were included. The primary variable was wRVU per hour of operative time (wRVU/h). Linear regression analysis was used to assess the relative influence that operative time had on wRVU/h.25,432 cases were included in the final study population from 45 unique CPT codes. The median operative time was 79 min, and the median RVU/h was 12.2. Procedures with operative time less than 79 min had higher wRVU/h compared with procedures longer than 79 min (14.5 vs 10.5, p 0.001). Procedures with higher than average incidence of any complications had a lower wRVU/h (9.0 vs. 14.6 p 0.001). Linear regression analysis revealed that each additional hour of operative time was expected to decrease wRVU/h by 4.2 (-0.70 per 10 min, 95% CI: -0.71 to -0.69, p 0.001; RThis analysis of contemporary large pediatric population national-level data suggests that the wRVU system significantly favors shorter and less complex procedures in Pediatric Urology. Pediatric urologists performing longer and more complex procedures are not adequately compensated for the increase in complexity.Retrospective comparative study.

The purpose of this study was to (1) report on the incidence of concurrent surgical pathology at the time of adolescent ACL reconstruction, (2) evaluate patient risk factors for concurrent pathology, and (3) measure the effect of BMI on operating room (OR) time. A retrospective analysis of the NSQIP database for the years 2005–2017 was conducted. Nine-hundred and seventeen patients 18 years of age and younger who underwent ACL reconstruction (ACLR) were identified using CPT code 29888 and patients undergoing surgery for multi-ligamentous knee injuries were excluded. The mean patient age was 17.6 years (range 14–18, standard deviation 0.52) and consisted of 546 males (59.5%) and 371 females (40.5%). Logistic regression was used to assess the relationship between BMI and additional CPT codes for internal derangement at the time of surgery. Internal derangement was defined as any procedure for the treatment of a meniscal tear, chondral lesion, or loose body removal. Linear regression analysis was then performed to evaluate the effect of BMI on operative time. 43.7% of patients undergoing ACLR required an associated procedure for internal derangement. Additionally, the risk of requiring additional procedures for internal derangement increased by 3.1% per BMI point. BMI was also predictive of operative time, independent of the number of additional procedures. Specifically, the operative time increased by nearly one minute for every point increase in BMI (58.0 s). Adolescent patients with an elevated BMI were much more likely to require additional surgical procedures for internal derangement at the time of ACL reconstruction. Additionally, BMI was a significant predictor for longer operative times. Level III.

Background Microsurgery is being increasingly utilized across surgical specialties, including plastic surgery. Microsurgical techniques require greater time and financial investment compared with traditional methods. This study aimed to evaluate 20-year trends in Medicare reimbursement and utilization for commonly billed reconstructive microsurgery procedures from 2000 to 2019. Methods Microsurgical procedures commonly billed by plastic surgeons were identified. Reimbursement data were extracted from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services for each current procedural terminology (CPT) code. All monetary data were adjusted for inflation to 2019 U.S. dollars. The average annual and total percentage changes in reimbursement were calculated based on these adjusted trends. To assess utilization trends, CMS physician/supplier procedure summary files were queried for the number of procedures billed by plastic surgeons from 2010 to 2018. Results After adjusting for inflation, the average reimbursement for all procedures decreased by 26.92% from 2000 to 2019. The greatest mean decrease was observed in CPT 20969 free osteocutaneous flaps with microvascular anastomosis (−36.93%). The smallest mean decrease was observed in repair of blood vessels with vein graft (−9.28%). None of the included procedures saw an increase in reimbursement rate over the study period. From 2000 to 2019, the adjusted reimbursement rate for all procedures decreased by an average of 1.35% annually. Meanwhile, the number of services billed to Medicare by plastic surgeons across the included CPT codes increased by 42.17% from 2010 to 2018. Conclusion This is the first study evaluating 20-year trends in inflation-adjusted Medicare reimbursement and utilization in reconstructive microsurgery. Reimbursement for all included procedures decreased over 20% during the study period, while number of services increased. Increased consideration of these trends will be important for U.S. policymakers, hospitals, and surgeons to assure continued access and reconstructive options for patients.

To investigate incidence and risk factors for postoperative complications after rectovaginal fistula (RVF) repairs, based on different surgical routes.This retrospective cohort study utilized CPT codes to identify RVF repairs performed during 2005 to 2017 from the American College of Surgeons National Surgical Quality Improvement Program database. Demographic/clinical characteristics were compared among different surgical routes. Logistic regression was performed to identify associations.Among 1398 RVF cases, 1391 were included for final analysis: 159 (11.4%) were performed transabdominally (group 1), 253 (18.2%) transperineally (group 2), and 979 (70.4%) transvaginally/transanally (group 3). Group 1 was older compared with groups 2 and 3 (58.72 ± 15.23 years vs 44.11 ± 13.51 years vs 46.23 ± 14.31 years, P0.0001). Race/ethnicity was comparable in all groups with non-Hispanic-White most common. Comparably, group 1 had higher preoperative comorbidities: hypertension requiring medication (P0.0001), chronic obstructive pulmonary disease (COPD) (P = 0.0347), preoperative infection (P = 0.002), functional dependence (P = 0.0001), and longer time between hospital admission to operation (P0.0001). Group 1 also had longer operating time (P0.0001); more American Society of Anesthesiologist ≥ 3 classification (P0.0001); and more likely inpatient status (P0.0001). The overall incidence of any postoperative complications was 13.2% (25.2%, group 1 vs 15.8%, group 2 vs 10.6%, group 3; P0.0001). The most common postoperative complications included unplanned readmission, postoperative superficial surgical site infection, and reoperation. The incidence of severe postoperative complications was 7.9% (17%, group 1 vs 7.1%, group 2 vs 6.6%, group 3, P0.0001): group 1 had highest rates of pulmonary embolism (P = 0.0004), deep venous thrombosis (P = 0.0453), bleeding requiring transfusion (P0.0001), stroke (P = 0.0207), unplanned reintubation (P = 0.0052), and death (P = 0.0004). Group 1 also had highest rates of minor postoperative complications like urinary tract infection (P = 0.0151), superficial surgical site infection (P = 0.0189), and pneumonia (P = 0.0103). In addition, group 1 had the greatest postoperative length of stay (P0.0001). In multivariate analysis, age (P = 0.0096), inpatient status at the time of surgery (P = 0.0004), and operating time2 to 3 hours (P = 0.0023) were significant predictors of postoperative complications within 30 days after surgery.The overall incidence of complications after RVF repairs+/-concomitant procedures was 13.2%. The overall incidence of severe complications was 7.9%. The abdominal approach had more postoperative complications but it was not an independent predictor of postoperative complications after RVF repair.

Rationale and Objectives In 2019, Centers for Medicare and Medicaid Services enforced regulation from the Affordable Care Act, requiring all U.S. hospitals to publish standard hospital charges annually. This study assesses top U.S academic hospitals’ chargemasters for selected advanced diagnostic imaging services and the usability of publicly available information to allow consumers to determine out-of-pocket costs. Materials and Methods Publicly available chargemasters and associated websites for the top 20 ranked hospitals in U.S. News and World Report were assessed for several features including: file format, inclusion of CPT codes, disclaimers on charges versus costs and professional fees, and tools allowing determination of actual out-of-pocket costs for selected advanced diagnostic imaging examinations. Results All hospitals had publicly available chargemasters, 90% of which were in Microsoft Excel format. Ten percent of chargemasters included CPT codes. All chargemaster websites had disclaimers regarding differences between charges versus patient costs; 20% had disclaimers regarding professional fees. 20% of hospitals provided out-of-pocket costs for uninsured patients or tools allowing out-of-pocket cost determination. Median (range) MR exam charges were: brain with and without contrast: $5375 ($834–$13,857), noncontrast knee: $3402 (4530–$6924); noncontrast lumbar spine: $ 3449 ($473–$7367). Median (range) CT exam charges were: noncontrast head: $1923 ($165–$4974), noncontrast chest: $1947 ($282–$2991); contrast abdomen/pelvis: $4307 ($486–$11,726). Conclusion While all top-ranked hospitals had publicly available chargemasters, they rarely provided transparent information to allow patients to determine out-of-pocket costs for advanced diagnostic imaging services.

This study evaluates the accuracy of reported the Accreditation Council for Graduate Medical Education (ACGME) operative case logs from graduated residents compared to institutional operating room electronic records (ORER). We hope this will help guide review committees and institutions develop complete, accurate resident case logs.This is a retrospective, cross-sectional study of general surgery (GS), neurosurgery (NS), and orthopedic surgery (OS) resident physicians. ACGME and ORER cases from 2009 to 2010 were analyzed and each case and current procedural terminology (CPT) code directly compared (ORER vs. ACGME).Single academic tertiary-care medical center (University of Kentucky, Lexington, KY).Eleven thousand nine hundred and twenty-three cases for 46 residents among the 3 residency programs were analyzed.There was an overall logging accuracy of 72% for ORER cases reflected in the ACGME case logs. OS residents had a higher rate of logging accuracy (OS 91%, GS 69%, NS 58%, chi-square p = 0.014) and mean annual number of cases compared to the other 2 programs (OS 452, GS 183, NS 237, ANOVA p = 0.001). NS residents had higher accuracy of CPT codes than post-graduate years 2 to 5 in other programs (p0.017). There was a strong positive correlation between the number of cases completed per resident and case logging accuracy, (rho = 0.769, p0.001) consistent for NS and GS, but not OS.This study shows only 72% of a residents' operative experience is captured in the ACGME case log across 3 surgical programs. There is significant variability among surgical programs and among post-graduate year cohorts regarding case log and CPT code accuracy. There is a strong correlation with the total number of cases performed and increasing case log accuracy. Low case log accuracy may reflect individual resident behavior instead of program operative exposure. Further studies are needed to determine if ORER may serve as a more complete assessment of the operative experience of a resident and program.

Studies show increasing use of urgent care centers (UCCs) and there is interest in evaluating their potential for cost savings. Previous research provides limited information on generalizable methods of identifying urgent care centers and does not validate these methods. The objective of this study is to describe and validate two claims-based UCC definitions. We used FAIR Health insurance claims from 444,263 organization National Provider Identifiers (NPIs) with at least 10 claims, January 2016–March 2019 and merged this data with National Plan and Provider Enumeration System data. The first definition required (1) a UCC place of service code (POS), (2) ≥ 10% Current Procedure Terminology (CPT) codes specific to UCCs, or (3) a UCC taxonomy code in the primary field. The second definition relaxed these criteria. A random sample of 5% of NPIs identified as UCCs were validated through internet searches. Prevalence and positive predictive value (PPV) were calculated for both definitions. The first definition identified 6669 (1.5%) of NPIs as UCCs resulting in a PPV of 92%. The second definition identified 8261 (1.9%) of NPIs as UCCs and had a PPV of 87%. Out of NPIs identified under the first definition, 96% were identified using POS codes, 50% were identified using taxonomy codes, and 46% using CPT codes, with 62% of NPIs meeting multiple criteria. Findings suggest that these methods may be used by researchers to identify UCCs in studies of cost or utilization in different healthcare settings.

Background Surgical site infection (SSI) rates are an important surgical quality metric. Decreased SSI rates have been demonstrated using negative pressure incisional wound vac device (NPIWV) dressings in adults but have not been studied in children. Materials and methods A retrospective review of patients treated with NPIWV at our institution between February 2016 and February 2018 was performed. NPIWV dressings were applied by previously described techniques. Using the same CPT codes from our study patients, we queried the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) data between January 2014 and January 2016 to identify preimplementation controls (PIC). NPIWV patients were compared to historical controls to assess safety and efficacy of SSI prevention. Results There were 32 patients managed with NPIWV, and 65 patients in the PIC group. There were no NPIWV-associated complications. There was a trend toward reduced incidence of SSI in NPIWV patients, with 1 SSI in 32 cases (3.1%) versus 7 SSIs in the 65 historical control patients (10.8%) (p = 0.22). Conclusions Our study shows that NPIWV dressings can be used safely in pediatric and neonatal patients undergoing surgery, with a trend toward decreased SSI rates. These findings should be confirmed in a larger, prospective trial. Type of study Retrospective comparative study. Level of evidence Level III.

Background The “intensity” of a surgical procedure is supposed to be incorporated into work RVUs to allow higher compensation rates for more complex procedures. However, updates to work RVUs are subjective and it is unclear if these intensity values correlate to objective measures of a procedure’s complexity. Methods Centers for Medicare and Medicaid Services (CMS) data were used to calculate intraservice intensity values for CPT codes in 2017 (“CMS intensity values”). Twenty-six objective measures– spanning patient, case, and risk characteristics - were generated using the 2017 participant use file from NSQIP. CMS intensity values were compared to objective measures using scatterplots and correlations. Results Among 473 CPT codes, CMS intensity values ranged from 0.0031 to 0.142 work RVUs/minute. CMS intensity values were positively associated with 3 objective measures, negatively associated with 5 measures, and not associated with the remaining 18 measures. Conclusions Despite intensity values – and therefore compensation rates - varying over 40-fold in the wRVU scale, there was generally no association between their magnitude and objective measures of surgical intensity.

BACKGROUND Plastic surgeons are evaluated not only by the number of patients served but also by relative value, quantified by the Medicare relative value unit system, which can affect advancement and compensation. Procedures that demand a high operative time without an increase in relative value units are, by definition, inefficient. The purpose of this study was to determine whether the number of relative value units actually corresponds to operative time. METHODS The National Surgical Quality Improvement Program data sets over a 9-year period were queried for plastic surgery operations. The primary CPT codes representing the 100 most common operations were compared for operative time and total relative value units. RESULTS A total of 53,701 cases were included. There was a high degree of correlation between operative time and number of relative value units (Pearson correlation coefficient, 0.82). The average efficiency was 10.201 ± 3.386 relative value units per hour. Pressure ulcer excisions and breast reconstruction were among the most efficient (e.g., Excision, sacral pressure ulcer, CPT 19357, generated 20.819 relative value units per hour). Skin excisions, debridements, and flap delays were among the least efficient (e.g., Excision, excessive skin and subcutaneous tissue, CPT 15847, generated 1.752 relative value units per hour). CONCLUSIONS As a general trend, the most common plastic surgical procedures requiring longer operative times are associated with more relative value units. Cases with higher relative value units assigned tended to be more efficient. For the 100 most common procedures, relative value units and operative time are not evenly distributed. These data suggest modifications to the current relative value unit designation system to more equally allocate these units based on effort and time.

While pelvic organ prolapse (POP) recurrence is believed to increase over time, outcomes of young women who undergo POP surgery are unclear. We hypothesized POP recurrence incidence among women

This article reviews the common Current Procedural Terminology (CPT) codes for frequently performed breast imaging procedures. The CPT codes for breast radiology services, including the revised codes for mammography, computer-assisted detection (CAD), breast ultrasound, breast magnetic resonance imaging (MRI), and imaging-guided breast interventional procedures and the new codes for digital breast tomosynthesis (DBT) and marker placement in axillary lymph nodes are outlined. The application of basic CPT coding principles, such as the use of modifiers and the different structure of code families in breast radiology services, is also discussed. CPT codes are updated on an ongoing basis to reflect the evolution of medical practice, and the CPT codes for breast imaging procedures have changed significantly in the past 5 years. These modifications can affect the distribution of work and utilization of resources in radiology departments. A working knowledge of coding practices will facilitate compliance with billing regulations and help ensure breast radiologists are appropriately paid for their work.

Many physicians share the perception that the work required to evaluate breast pathology specimens is undervalued by Current Procedural Terminology (CPT) codes. To examine this issue, we compared slide volumes from an equal number of breast and nonbreast specimens assigned 88305, 88307, or 88309 CPT codes during four 2.5-week periods over 1 year. For each specimen, a number of initial hematoxylin and eosin-stained sections (H&Es), preordered additional H&E sections (levels), H&E sections ordered after initial slide review (recuts), and specimen type were recorded. Slides associated with ancillary stains were not considered. In total, 911 breast and 911 nonbreast specimens, each assigned 88305 (n=580), 88307 (n=320), and 88309 (n=11) CPT codes, were compared. Breast 88305 specimens were mainly core biopsies and margins and generated 2.3 and 6.4 times the H&Es and recuts, respectively, than did nonbreast specimens (P

This article describes the method by which U.S. health care services are valued and reimbursed, and the essential role practicing physicians, including breast imaging radiologists, and medical specialty societies play in this process. The American Medical Association has described the method for developing new and revised Current Procedural Terminology (CPT) codes as a 3-legged stool, with patient care as the seat supported by its legs: the CPT process (where the work is described), the Relative Value Scale Update Committee (RUC) process (where the work is valued), and coverage by Medicare (where the work is paid). Although the future direction of health care payment policy in the USA is uncertain and difficult to predict, CPT codes remain the foundation for the reimbursement of physician services. A working knowledge of the CPT process can be valuable to breast imaging radiologists, both for managing their practices at the current time and preparing them for future changes in payment policy.

The risk of colorectal cancer increases with age, and the number of older adults requiring operations has increased. The purpose of this study was to determine whether a current risk calculator can accurately predict operative mortality for rectal cancer and whether the predictive accuracy varied with age.The American College of Surgeons NSQIP database using ICD-9/10 codes for rectal cancer and CPT codes for proctectomy was accessed (2012 to 2015). The prognostic value of the risk calculator was evaluated using the predicted mortality variable code. Age categories were 18 to 64 years, 65 to 79 years, and 80 to 89 years. Analysis of variance was performed to assess differences between age categories in predicted and actual mortality and Pearson correlation coefficients were computed. Logistic regression models were constructed to evaluate associations adjusted for key covariates.There were 9,289 patients included, with age distribution as follows: 18 to 64 years (n = 5,674), 65 to 79 years (n = 2,899), and 80 to 89 years (n = 716). Both predicted and actual mortality increased with age, adjusting for functional status, comorbidity, and other covariates (p 0.0001). The overall correlation between predicted and actual mortality was low (r = 0.20). The correlation was weakest from 18 to 64 years (r = 0.07), strongest from 65 to 79 years (r = 0.25), and in between from 80 to 89 years (r = 0.13). Predicted mortality was overestimated in the 18 to 64 years and underestimated in both the 65 to 79 years and 80 to 89 years age groups. Predicted mortality by age category interaction terms was also significantly associated with actual mortality in covariate-adjusted logistic regression models, providing additional evidence that the accuracy of predicted mortality varies by age.The American College of Surgeons NSQIP mortality risk estimates appear to be poorly associated with actual mortality and the accuracy might differ between younger and older patients with primary rectal cancer. Goals of care discussion with the older patient about outcomes are indicated, as there is an almost twice predicted mortality.

OBJECTIVES: The creation and maintenance of durable hemodialysis access is critically important for reducing patient morbidity and controlling overall costs within health systems. Our objective was to quantify the costs associated with hemodialysis access creation and its maintenance over time within a rate-controlled health system where charges equate to payments. METHODS: The Maryland Health Services Cost Review Commission administrative claims database was used to identify patients who underwent first-time access creation from 2012–2020. Patients were identified using CPT codes for access creation, and costs were accrued for the initial encounter and all subsequent outpatient access-related encounters. T-tests and Wilcoxon tests were used to compare reinterventions and access-related costs ($USD) between arteriovenous fistulae (AVF) and arteriovenous grafts (AVG). Multivariable modeling was used to quantify the association of access type with charge variation. RESULTS: Overall, 12,716 patients underwent first-time access creation (69.3% AVF vs. 30.7% AVG). There was no difference in freedom from reintervention between the two access types at any point following creation (HR: 1.03, 95%CI: 0.97–1.10); however, AVF were associated with a lower number of cumulative reinterventions (1.50 vs. 2.24) compared to AVG (P

OBJECTIVES: Poor glycemic control (GC) is associated with poorer executive function. However, data looking at the relationship between GC and cognition is limited. This study aimed to assess the relationship between GC and various cognitive tests using electronic medical record data (EMR). Hemoglobin A1c (HbA1c) was the main predictor variable. METHODS: De-identified data were gathered from an midwestern academic medical center's EMR in an i2b2 based clinical data repository. Participants were seen at the hospital's memory clinic with a HbA1c lab value (CPT Code: 83,036) on record. 566 participants were used in the final analysis. The most recent cognitive score from the following cognitive tests were used as the response variables, Trail Marking Part A and B and Verbal Fluency. The median value was derived from each participant's three most recent HbA1c values. We constructed ordinary least squares regression models to assess HbA1c's relationship with individual cognitive tests. The model included race, Mild Cognitive Impairment, Alzheimer's Disease, income, and age as covariates. Statistical analyses were performed using R (v. 3.6.2; R Foundation, Vienna, Austria). Statistical significance was set at p

Objective: CDC’s recent data (Harding et al. 2020) showed that rates of major lower-extremity amputations (ankle or above) rapidly decreased in 2000 - 2010 and then stabilized at slightly lower than 0.1% of Medicare beneficiaries with diabetes since then. We examined the commonwealth of Kentucky (KY) inpatient data to track trends in diabetic major amputations in 2008 - 2018. Methods: We used KY HCUP inpatient data to identify all patients with diabetes using ICD9/10 codes and those who have underwent major amputations using CPT codes. Results: The number of hospitalizations by patients with diabetes in KY decreased by 8% in 2008 - 2018 but the number of major amputations increased from 560 to 795 limbs, representing a 42% increase in the same period. Medicare paid for 44% of these surgeries in 2008 and 61% in 2018, while Medicaid covered 38% in 2008 but only 31% in 2018 despite the expansion in Medicaid coverage since 2014. KY inpatient users with diabetes had 46% higher odds of having a major amputation in 2018 compared to those in 2008, adjusting for age, sex, and race/ethnicity. Compared to pre-2014 era, the odds of having a major amputation was 27% higher after the Medicaid expansion in 2014. Conclusion: It is concerning that, while the rest of the country showed decreasing or stationary trends in major amputation rates, KY experienced continuously increasing number of major amputations in the last two decades. Although Medicaid expansion era had a significantly higher odds of major amputations compared to the pre-expansion era, it is not clear whether this reflects the effect of policy or is part of a secular trend since 2010. More careful analysis is needed to better understand the underlying causes of this trend and what needs to done to reverse it. Disclosure M. Sohn: None. W. Kim: None. M. Lacy: None.

In 2019, the 2 Current Procedural Terminology (CPT) codes for skin biopsies were replaced with 6 new CPT codes to allow for technique specification and differential reimbursement. We sought to evaluate whether the concurrent decrease in reimbursement for shave biopsies and increase in reimbursement for punch biopsies led to utilization changes. We examined shave and punch biopsies submitted for pathologic examination at 3 academic centers in May 2018 and May 2019. We performed χ2 tests to evaluate for changes in the ratio of biopsy utilization over time, with subgroup analyses by practice setting and provider type. Totals included 11,785 (12.11% punch) and 11,291 (12.08% punch) biopsies submitted in May 2018 and May 2019, respectively. Our results demonstrate small yet important changes in biopsy use patterns within the context of recent reimbursement changes when analyzing academic and private practices separately. Although small in magnitude, this change in behavior may have a substantial impact when extrapolated to behavior across the nation.