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procedure Valuation: How a code Becomes an RVU and a Review of the Current Literature

CURRENT OTORHINOLARYNGOLOGY REPORTS 2024年第3期12卷 103-107页

作者： Quinton, Brooke A. Quereshy, Humzah A. Cleveland, Chelsea Hayden, Jamil Shah, Jay R. Case Western Reserve Univ Sch Med Cleveland OH USA Univ Hosp Cleveland Dept Otolaryngol Head & Neck Surg Med Ctr 11100 Euclid AveSte 170 Cleveland OH 44106 USA

Purpose of Review The goal of this review is to describe the complex process by which a procedure code is assigned value using relative value units (RVUs) and discuss current research that assesses the objectivity and equity of the *** Findings While research on this topic is somewhat limited, the authors of a majority of studies call for revaluation of common codes within their surgical specialty due to misvaluation when comparing current RVU scales with national procedure time data. In addition, several studies report that the current system does not adequately reflect patient-based factors that influence physician workload during a case. Finally, certain small subspecialties and pediatric subspecialties in surgical fields are particularly vulnerable to *** procedure valuation is critically important for surgeons to understand to ensure advocacy for their field and their patients. Continued research using large, national datasets will provide evidence for needed improvements in objectivity in this process and increased surgeon participation in this committee-based decision is imperative for equitable change.

关键词： Relative value unit procedure code Physician reimbursement Medicare Healthcare policy

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The method to identify invasive mechanical ventilation with Japanese claim data

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JOURNAL OF INTENSIVE CARE 2024年第1期12卷 48页

作者： Sakamoto, Ayaka Inoue, Yoshiaki Univ Tsukuba Hosp Dept Emergency & Crit Care Med 2-1-1 Amakubo Tsukuba Ibaraki 3058576 Japan Univ Tsukuba Grad Sch Comprehens Human Sci 1-1-1 Tenno Dai Tsukuba Ibaraki 3058577 Japan Univ Tsukuba Inst Med Dept Emergency & Crit Care Med 1-1-1 Tennodai Tsukuba Ibaraki 3058577 Japan

Dr. Ohbe et al. reported that only 40.4% of patients who underwent invasive mechanical ventilation were treated in intensive care units, with significant variations in intensive care unit admission rates observed between hospitals and regions using Japanese claims data. The issue of validation when using claim data has been reported in previous studies. The definition of invasive mechanical ventilation used by Dr. Ohbe et al. appears overly broad, encompassing non-invasive mechanical ventilations via nasal mask and manual ventilation. We discuss the limitation of their method in identifying invasive mechanical ventilation, which is critical for defining the study population.

关键词： Invasive mechanical ventilation Claim data procedure code Japan

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How Medical Services Get Valued

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SEMINARS IN INTERVENTIONAL RADIOLOGY 2023年第5期40卷 437-440页

作者： Krol, Katharine L.

The mechanisms for Medicare payment to physicians are complicated and, in fee for service Medicare, the value of a procedure code explicitly determines the payment to the physician and the out-of-pocket cost to the beneficiary. These codes are created and then valued for payment through a complex but reproducible and transparent process that allows for physician and specialty society input. This article describes the process and its implications for interventional radiology.

关键词： relative value unit CPT procedure code interventional radiology Medicare RUC CMS

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Validating surgical procedure codes for inflammatory bowel disease in the Swedish National Patient Register

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BMC MEDICAL INFORMATICS AND DECISION MAKING 2019年第1期19卷 217-217页

作者： Forss, Anders Myrelid, Par Olen, Ola Everhov, Asa H. Nordenvall, Caroline Halfvarson, Jonas Ludvigsson, Jonas F. Karolinska Inst Dept Med Epidemiol & Biostat Box 281 SE-17177 Stockholm Sweden Linkoping Univ Linkoping Univ Hosp Dept Clin & Expt Med Fac Hlth Linkoping Sweden Karolinska Inst Dept Med Solna Clin Epidemiol Unit Stockholm Sweden Stockholm South Gen Hosp Sachs Children & Youth Hosp Stockholm Sweden South Gen Hosp Dept Clin Sci & Educ Stockholm Sweden Karolinska Inst Dept Mol Med & Surg Stockholm Sweden Karolinska Univ Hosp Ctr Digest Dis Div Coloproctol Stockholm Sweden Orebro Univ Fac Med & Hlth Dept Gastroenterol Orebro Sweden Orebro Univ Hosp Dept Paediat Orebro Sweden Univ Nottingham Sch Med Div Epidemiol & Publ Hlth Nottingham England Columbia Univ Coll Phys & Surg Dept Med New York NY USA

Background About 50% of patients with Crohn's disease (CD) and about 20% of those with ulcerative colitis (UC) undergo surgery at some point during the course of the disease. The diagnostic validity of the Swedish National Patient Register (NPR) has previously been shown to be high for inflammatory bowel disease (IBD), but there are little data on the validity of IBD-related surgical procedure codes. Methods Using patient chart data as the gold standard, surgical procedure codes registered between 1966 and 2014 in the NPR were abstracted and validated in 262 randomly selected patients with a medical diagnosis of IBD. Of these, 53 patients had reliable data about IBD-related surgery. The positive predictive value (PPV), sensitivity and specificity of the surgical procedure codes were calculated. Results In total, 158 surgical procedure codes were registered in the NPR. One hundred fifty-five of these, representing 60 different procedure codes, were also present in the patient charts and validated using a standardized form. Of the validated codes 153/155 were concordant with the patient charts, corresponding to a PPV of 96.8% (95%CI = 93.9-99.1). Stratified in abdominal, perianal and other surgery, the corresponding PPVs were 94.1% (95%CI = 88.7-98.6), 100% (95%CI = 100-100) and 98.1% (95%CI = 93.1-100), respectively. Of 164 surgical procedure codes in the validated patient charts, 155 were registered in the NPR, corresponding to a sensitivity of the surgical procedure codes of 94.5% (95%CI = 89.6-99.3). The specificity of the NPR was 98.5% (95%CI = 97.6-100). Conclusions Data on IBD-related surgical procedure codes are reliable, with the Swedish National Patient Register showing a high sensitivity and specificity for such surgery.

关键词： Epidemiology Inflammatory bowel disease Validation National Patient Register procedure code

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Validation of an electronic coding algorithm to identify the primary indication of orthopedic surgeries from administrative data

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BMC MEDICAL INFORMATICS AND DECISION MAKING 2020年第1期20卷 187-187页

作者： Giardina, John C. Cha, Thomas Atlas, Steven J. Barry, Michael J. Freiberg, Andrew A. Leavitt, Lauren Marques, Felisha Sepucha, Karen Harvard TH Chan Sch Publ Hlth Ctr Hlth Decis Sci 718 Huntington Ave Boston MA 02115 USA Massachusetts Gen Hosp Dept Orthopaed Surg Boston MA 02114 USA Harvard Med Sch Boston MA 02115 USA Massachusetts Gen Hosp Div Gen Internal Med Boston MA 02114 USA

BackgroundDetermining the primary indication of a surgical procedure can be useful in identifying patients undergoing elective surgery where shared decision-making is recommended. The purpose of this study was to develop and validate an algorithm to identify patients receiving the following combinations of surgical procedure and primary indication as part of a study to promote shared decision-making: (1) knee arthroplasty to treat knee osteoarthritis (KOA);(2) hip arthroplasty to treat hip osteoarthritis (HOA);(3) spinal surgery to treat lumbar spinal stenosis (SpS);and (4) spinal surgery to treat lumbar herniated disc (HD).MethodsConsecutive surgical procedures performed by participating spine, hip, and knee surgeons at four sites within an integrated care network were included. Study staff reviewed electronic medical records to ascertain a "gold standard" determination of the procedure and primary indication status. Electronic algorithms consisting of ICD-10 and CPT codes for each combination of procedure and indication were then applied to records for each case. The primary measures of validity for the algorithms were the sensitivity and specificity relative to the gold standard *** surgeons performed 790 procedures included in this study. The sensitivity of the algorithms in determining whether a surgical case represented one of the combinations of procedure and primary indication ranged from 0.70 (HD) to 0.92 (KOA). The specificity ranged from 0.94 (SpS) to 0.99 (HOA, KOA).ConclusionThe electronic algorithm was able to identify all four procedure/primary indication combinations of interest with high specificity. Additionally, the sensitivity for the KOA cases was reasonably high. For HOA and the spine conditions, additional work is needed to improve the sensitivity of the algorithm to identify the primary indication for each case.

关键词： Electronic medical record Algorithm validation Diagnostic code procedure code Orthopedic surgery Elective surgery Shared-decision making

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Prime :: Doc :: Doc10055-1La Advanced Pgmrs Guide Vol1 Sep85

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2016年

Prime :: Doc :: Doc10055-1La Advanced Pgmrs Guide Vol1 Sep85 by published by

关键词： advanced bind doc10055-1la dynamic linking edition entrypoint entrypoint search epf epfs fixed bin guide library library epf library epfs linkage linkage area linkage text pgmrs prime procedure code program program epf search list subroutine subroutines

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Evaluating predictive modeling algorithms to assess patient eligibility for clinical trials from routine data

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BMC MEDICAL INFORMATICS AND DECISION MAKING 2013年第1期13卷 1-9页

作者： Koepcke, Felix Lubgan, Dorota Fietkau, Rainer Scholler, Axel Nau, Carla Stuerzl, Michael Croner, Roland Prokosch, Hans-Ulrich Toddenroth, Dennis Univ Erlangen Nurnberg Chair Med Informat D-91054 Erlangen Germany Erlangen Univ Hosp Dept Radiat Oncol Erlangen Germany Erlangen Univ Hosp Dept Anesthesiol Erlangen Germany Erlangen Univ Hosp Div Mol & Expt Surg Erlangen Germany Erlangen Univ Hosp Dept Surg Erlangen Germany

Background: The necessity to translate eligibility criteria from free text into decision rules that are compatible with data from the electronic health record (EHR) constitutes the main challenge when developing and deploying clinical trial recruitment support systems. Recruitment decisions based on case-based reasoning, i.e. using past cases rather than explicit rules, could dispense with the need for translating eligibility criteria and could also be implemented largely independently from the terminology of the EHR's database. We evaluated the feasibility of predictive modeling to assess the eligibility of patients for clinical trials and report on a prototype's performance for different system configurations. Methods: The prototype worked by using existing basic patient data of manually assessed eligible and ineligible patients to induce prediction models. Performance was measured retrospectively for three clinical trials by plotting receiver operating characteristic curves and comparing the area under the curve (ROC-AUC) for different prediction algorithms, different sizes of the learning set and different numbers and aggregation levels of the patient attributes. Results: Random forests were generally among the best performing models with a maximum ROC-AUC of 0.81 (CI: 0.72-0.88) for trial A, 0.96 (CI: 0.95-0.97) for trial B and 0.99 (CI: 0.98-0.99) for trial C. The full potential of this algorithm was reached after learning from approximately 200 manually screened patients (eligible and ineligible). Neither block- nor category-level aggregation of diagnosis and procedure codes influenced the algorithms' performance substantially. Conclusions: Our results indicate that predictive modeling is a feasible approach to support patient recruitment into clinical trials. Its major advantages over the commonly applied rule-based systems are its independency from the concrete representation of eligibility criteria and EHR data and its potential for automation.

关键词： Random Forest Electronic Health Record procedure code Clinical Decision Support System Electronic Health Record Data

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Carotid endarterectomy and carotid artery stenting utilization trends over time

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BMC NEUROLOGY 2012年第1期12卷 17-17页

作者： Skerritt, Matthew R. Block, Robert C. Pearson, Thomas A. Young, Kate C. Dept Community & Prevent Med Rochester NY 14642 USA Clin & Translat Sci Inst Rochester NY USA Univ Rochester Med Ctr Dept Neurol Rochester NY USA

Background: Carotid endarterectomy (CEA) has been the standard in atherosclerotic stroke prevention for over 2 decades. More recently, carotid artery stenting (CAS) has emerged as a less invasive alternative for revascularization. The purpose of this study was to investigate whether an increase in stenting parallels a decrease in endarterectomy, if there are specific patient factors that influence one intervention over the other, and how these factors may have changed over time. Methods: Using a nationally representative sample of US hospital discharge records, data on CEA and CAS procedures performed from 1998 to 2008 were obtained. In total, 253,651 cases of CEA and CAS were investigated for trends in utilization over time. The specific data elements of age, gender, payer source, and race were analyzed for change over the study period, and their association with type of intervention was examined by multiple logistic regression analysis. Results: Rates of intervention decreased from 1998 to 2008 (P < 0.0001). Throughout the study period, endarterectomy was the much more widely employed procedure. Its use displayed a significant downward trend (P < 0.0001), with the lowest rates of intervention occurring in 2007. In contrast, carotid artery stenting displayed a significant increase in use over the study period (P < 0.0001), with the highest intervention rates occurring in 2006. Among the specific patient factors analyzed that may have altered utilization of CEA and CAS over time, the proportion of white patients who received intervention decreased significantly (P < 0.0001). In multivariate modeling, increased age, male gender, white race, and earlier in the study period were significant positive predictors of CEA use. Conclusions: Rates of carotid revascularization have decreased over time, although this has been the result of a reduction in CEA despite an overall increase in CAS. Among the specific patient factors analyzed, age, gender, race, and time were signifi

关键词： Carotid Endarterectomy procedure code Carotid Artery Stenting Nationwide Inpatient Sample Secondary Stroke Prevention

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Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems

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BMC FAMILY PRACTICE 2012年第1期13卷 2-2页

作者： Vikstrom, Anna Hagglund, Maria Nystrom, Mikael Strender, Lars-Erik Koch, Sabine Hjerpe, Per Lindblad, Ulf Nilsson, Gunnar H. Karolinska Inst Dept Neurobiol Care Sci & Soc Ctr Family & Community Med SE-14183 Huddinge Sweden Karolinska Inst Dept Learning Informat Management & Eth Hlth Informat Ctr HIC SE-17177 Stockholm Sweden Linkoping Univ Dept Biomed Engn SE-58185 Linkoping Sweden Skaraborg PC R&D Ctr Skovde Sweden Lund Univ Dept Clin Sci Fac Med S-22100 Lund Sweden Univ Gothenburg Dept Publ Hlth & Community Med Primary Hlth Care Sahlgrenska Acad Gothenburg Sweden

Background: procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVA) and SNOMED CT. Methods: procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed. Results: 417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions. Conclusions: procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT. Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.

关键词： Primary Care Health Care Professional procedure code Electronic Patient Record International Statistical Classification

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DRG coding practice: a nationwide hospital survey in Thailand

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BMC HEALTH SERVICES RESEARCH 2011年第1期11卷 1-10页

作者： Pongpirul, Krit Walker, Damian G. Rahman, Hafizur Robinson, Courtland Chulalongkorn Univ Fac Med Dept Prevent & Social Med Bangkok 10330 Thailand Johns Hopkins Bloomberg Sch Publ Hlth Dept Int Hlth Baltimore MD USA

Background: Diagnosis Related Group (DRG) payment is preferred by healthcare reform in various countries but its implementation in resource-limited countries has not been fully explored. Objectives: This study was aimed (1) to compare the characteristics of hospitals in Thailand that were audited with those that were not and (2) to develop a simplified scale to measure hospital coding practice. Methods: A questionnaire survey was conducted of 920 hospitals in the Summary and Coding Audit Database (SCAD hospitals, all of which were audited in 2008 because of suspicious reports of possible DRG miscoding);the questionnaire also included 390 non-SCAD hospitals. The questionnaire asked about general demographics of the hospitals, hospital coding structure and process, and also included a set of 63 opinion-oriented items on the current hospital coding practice. Descriptive statistics and exploratory factor analysis (EFA) were used for data analysis. Results: SCAD and Non-SCAD hospitals were different in many aspects, especially the number of medical statisticians, experience of medical statisticians and physicians, as well as number of certified coders. Factor analysis revealed a simplified 3-factor, 20-item model to assess hospital coding practice and classify hospital intention. Conclusion: Hospital providers should not be assumed capable of producing high quality DRG codes, especially in resource-limited settings.

关键词： Exploratory Factor Analysis procedure code Diagnosis Relate Group Discharge Summary Hospital Provider

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