Turning whine into wine: the fiscal impact of comprehensive documentation and billing for nonoperative pediatric surgical services

Purpose

Some pediatric surgeons rarely document nonoperative services, believing that the reimbursement provided for such care is negligible. We evaluated the impact of comprehensive documentation and billing for nonoperative, pediatric surgical care.

Methods

All bills submitted for inpatient, nonoperative care for 1 year were reviewed. Total receipts for documented admissions, consultations, critical care, and daily care were determined. The Evaluation and Management code billed for each service was recorded, and the total and average payments attributable to each Evaluation and Management code were calculated.

Results

Fifty-six percent of services were covered by Medicaid and 26% by a commercial insurer. There were 607 billed admission history and physical exams for which reimbursement totaled $43,493. Critical care services were provided to 49 patients and yielded $8964 in payments. Six hundred thirty-nine inpatient consultations were performed with a reimbursement of $42,830. Daily care services were billed 1044 times and produced $71,579 in payments. Overall reimbursement for documented, nonoperative services was $166,866. This represented 16.2% of total, noncontracted income for the practice.

Conclusion

Despite a payer mix heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what it would have been had only operative services been billed. The yield from properly documented, nonoperative care can be substantial.     

Ventrodorsale Korrektur und Instrumentation idiopathischer Skoliosen

A number of different procedures are used for the surgical treatment of King II scoliosis. One reason for the controversial discussion in this context is that the term King II scoliosis is usually inadequate, because there are partly marked clinical and radiological differences in this type of curvature. From January 1996 to December 1997, a total of 26 patients with rigid King II scoliosis were submitted to a ventrodorsal procedure. Twenty-three patients were included in the study. The indication for this procedure was established in cases with a secondary lumbar curvature of at least 50 degrees as well as unsatisfactory straightening of the primary and secondary curvature in the bendings and inadequate horizontal positioning of the caudal end vertebra of not less than 10 degrees. Ventral Derotation-Spondylodesis (VDS) and Dorsal correction-Spondylodesis (DKS) led to a thoracic and lumbar straightening from 68.4 degrees to 13.2 degrees and from 61.4 degrees to 17.8 degrees, respectively. The tilt of the vertebra instrumented farthest caudally was corrected from 21.2 degrees to 4.9 degrees. The thoracic hypokyphosis was improved from 16.6 degrees to 25.1 degrees. In 11 patients, the dorsal instrumentation was extended to the caudal end vertebra, in another 11 patients, instrumentation was achieved up to a vertebra cranial from the end vertebra. The correction loss and complication rate was extremely low. Based on the surgical goals discussed further down, combined application of VDS and DKS is efficient and suitable in conjunction with the indication described. The complication rate is quite low. The different types of King II scoliosis have to be differentiated preoperatively.     

First trimester of pregnancy laparoscopic procedures

Laparoscopic procedures are being performed during pregnancy with increasing frequency; however, few first-trimester operations have been published. Two first-trimester procedures are here reported, both performed with uneventful recoveries. Received: 25 March 1996/Accepted: 24 January 1997     

Current status of extracorporeal shock wave lithotripsy

Summary Extracorporeal shock wave lithotripsy (ESWL) is standard therapy for urolithiasis. With comparable technical principles, various lithotripters have been developed and are in routine use. Renal pelvic stones, calyceal stones, ureteral stones, and other special forms can be treated with varying results. Currently, the so-called clinically insignificant residual fragments and the recurrence of calculi are under discussion. Whereas the side effects of ESWL are well known, studies comparing ESWL with other endourological procedures are still lacking.      

Is coding of diagnoses,comorbidities, and complications in total knee arthroplasty accurate?

Coding of diagnoses, comorbidities, and complications is important for health care delivery, not only for appropriate hospital and physician reimbursement, but also for a correct assessment of complication rates. The purpose of this study was to determine the agreement of coding of diagnoses, comorbidities, and complications for total knee arthroplasty between 2 groups of coders. Between January 1, 1997, and November 18, 1997, 100 consecutive primary total knee arthroplasties were done by 2 orthopaedic surgeons. Diagnoses, comorbidities, and complications were coded by professional hospital coders according to the Healthcare Finance Administration guidelines, then recoded by a second team with orthopaedic experience. Although the hospital coders matched diagnoses with the orthopaedic team 96.5% of the time, they determined a complication rate of 1.4 per patient and a comorbidity rate of 2.9 per patient, whereas the orthopaedic team coded for 0.7 complications per patient and 3.7 comorbidities. Based on these results, there should be interaction and communication between hospital coders and health care professionals to check that coding is accurate and reproducible.     

Besonderheiten bei der Abrechnung von gefäßchirurgischen DRG-Fallpauschalen

The German healthcare system is under construction. An important element of the reform concerns the recently created G-DRG system. The Alfried-Krupp-Krankenhaus took the opportunity offered by the German government to switch to DRG-based payments for inpatients as of 1 January 2003. Based on 8 months of experience with the new system, we present issues specific to the field of vascular surgery and contrast the old reimbursement system with the new DRG system for various treatments. In comparison to the former Fallpauschalen/Sonderentgelt system, administrative procedures must be adjusted to avoid unanticipated shortfalls in revenues. Through teamwork, the hospital management and medical controlling identified indicators to screen for poorly or incorrectly coded cases. For this purpose an IT system was implemented as part of the hospital information system, thus enabling control and optimization of coding to become reality. To make coding easy for doctors and, at the same time, profitable for the hospital, a selection of the most relevant ICD codes are automatically displayed for the top ten DRGs. As a result, a profit can be secured even during the difficult time of transition to the reimbursement system.     

Aspects of signing a permission for imprisonment for arrested patients during on call services

Summary A common problem for Emergency Room doctors on call is whether or not an arrested patient is sufficiently healthy to allow his transfer to jail. When there are signs of injury, or doubts about the patient's condition, the police must bring the patient in for medical examination to get a certification of the patient's health condition. He must be examined according to the information about his health and pre-existing conditions. Additional treatment should be undertaken, depending on patient's condition. The diagnoses must be written and summarized accurately and concisely. Additional documentation, such as photographic evidence must also be saved in the medical records. Should there be symptoms of a serious but difficult to diagnose condition, like traumatic head injury, the patient should always be admitted to the hospital. The medical certification or permission for imprisonment can not be enforced when the medical condition of the patient changes.      

Shock wave treatment in orthopedics

Summary Extracorporeal shock waves have revolutionized urological stone treatment. Nowadays shock waves are widely used in orthopedics, too. This article reviews the applications of extracorporeal shock waves on bone and adjacent soft tissue. The osteoneogenetic effect of extracorporeal shock waves has been proven and can be used to treat pseudarthrosis with a success rate of around 75 %. Shock waves have a positive effect in tennis and golfer's elbow, calcaneal spur, and the complex called “periarthritis humeroscapularis.” The mechanism for this is not yet known, and results from large prospective and randomized studies are still lacking. However, the treatment has been performed many thousands of times. In patients in whom conservative treatment has failed surgery used to be the only choice, but its success rate barely exceeds that of shock wave therapy and surgery can still be done if shock wave therapy fails. Extracorporeal shock waves will have an impact on orthopedics comparable to its effect in urology. Scientific evaluations, professional certifications, quality assurance and reimbursement issues present great challenges.      

Prospective, blinded evaluation of accuracy of operative reports dictated by surgical residents

Incomplete or inaccurate operative notes result in delayed, reduced, or denied reimbursement. Deficient reports may be more common when dictated by the surgical residents. We performed a blinded study to assess the accuracy of residents' dictations and their effect on the appropriate level of coding for reimbursement. A prospective, blinded study was performed comparing operative reports dictated by senior surgical residents (postgraduate years 3, 4, and 5) to reports dictated by attending surgeons. All residents had previously undergone group instruction on the importance and structure of operative notes. The trainees were blinded to the fact that the attending surgeons were dictating the operative reports on a separate dictation system. The dictations were analyzed by faculty reimbursement billing personnel for accuracy and completeness. Fifty operative reports of general surgical procedures dictated by both surgical residents and attending physicians were reviewed. A total of 97 CPT codes were used to report services rendered. Residents' dictations resulted in incorrect coding in 14 cases (28% error rate). The types of inaccuracies were a completely missed procedure (4) and insufficient documentation for an appropriate CPT code and/or modifier (10). All deficiencies occurred in complex, multicode, and/or laparoscopic cases. Sixty-seven per cent of late dictations were incomplete. The financial analysis revealed that deficiencies in resident dictations would have reduced the reimbursement by $18,200 (9.7%). For cases with deficient dictations, 29.5 per cent of charges would have been missed, delayed, or denied if the resident-dictated note was used to justify charges. Operative reports dictated by surgical residents are often incomplete or inaccurate, likely leading to reduced or delayed reimbursement. Dictations of complex, multicode, or laparoscopic surgeries, especially if delayed beyond 24 hours, are likely to contain significant deficiencies that affect billing. Attending surgeons may be better equipped to dictate complex cases. Formal housestaff education, mentorship by the attending faculty, and ongoing quality control may be paramount to minimize documentation errors to ensure appropriate coding for the services rendered.     

Interobserver variance in diagnostic arthroscopy of the knee

Summary We assessed the interindividual diagnostic variance of 39 experienced arthroscopists by the Kappa Cohen interobserver variation analysis using videotapes of eight different patients with different diagnoses. Arthroscopically normal findings showed a relatively acceptable interobserver correlation. Pathological changes, in contrast, often showed very little correlation, especially in the synovial membrane of the suprapatellar recess, in the cartilage of the femoropatellar groove and the posterior cruciate ligament. In patellar alignment there was also great interobserver variation. Clinical relevance: When comparing arthroscopic findings with other imaging techniques the above results should be taken into account. Furthermore, these results will affect the significance of medical expertise based only on pictures. In addition, medical cost billing, which is based on arthroscopic findings, has to take into account that a wrong diagnosis is possible and therefore charges will be wrong.      

Einführung eines Patientendatenmanagementsystems

Background

Patient data management systems (PDMS) enable digital documentation on intensive care units (ICU) and have positive effects on completness, quality and quantity of documented information. A commercial PDMS was implemented in a 25-bed ICU replacing paper-based patient charting. The ICU electronic patient record is completely managed inside the PDMS. IT compiles data from vital signs monitors, ventilators and further medical devices and facilitates some drug dose and fluid balance calculations as well as data reuse for administrative purposes. Ventilation time and patient severity scoring as well as coding of diagnoses and procedures is supported. Billing data transferred via interface to the central billing system of the hospital. Such benefits should show in measurable parameters, such as documented ventilator time, number of coded diagnoses and procedures and others. These parameters influence reimbursement in the German DRG system. Therefore, measurable changes in cost and reimbursement data of the ICU were expected.

Material and methods

A retrospective analysis of documentation quality parameters, cost data and mortality rate of a 25-bed surgical ICU within a German university hospital 3 years before (2004–2006) and 5 years after (2007–2011) PDMS implementation. Selected parameters were documented electronically, consistently and reproducibly for the complete time span of 8 years including those years where no electronic patient recording was available. The following parameters were included: number of cleared DRG, cleared ventilator time, case mix (CM), case mix index (CMI), length of stay, number of coded diagnoses and procedures, detailed overview of a specific procedure code based on daily Apache II and TISS Core 10 scores, mortality, total ICU costs and revenues and partial profits for specific ICU procedures, such as renal replacement therapy and blood products.

Results

Systematic shifts were detected over the study period, such as increasing case numbers and decreasing length of stay as well as annual fluctuations in severity of disease seen in the CM and CMI. After PDMS introduction, the total number of coded diagnoses increased but the proportion of DRG relevant diagnoses dropped significantly. The number of procedures increased (not significantly) and the number of procedures per case did not rise significantly. The procedure 8-980 showed a significant increase after PDMS introduction whereas the DRG-relevant proportion of those procedures dropped insignificantly. The number of ventilator-associated DRG cases as well as the total ventilator time increased but not significantly. Costs and revenues increased slightly but profit varied considerably from year to year in the 5 years after system implementation. A small increase was observed per case, per nursing day and per case mix point. Additional revenues for specific ICU procedures increased in the years before and dropped after PDMS implementation. There was an insignificant increase in ICU mortality rate from 7.4?% in the year 2006 (before) to 8.5?% in 2007 (after PDMS implementation). In the following years mortality dropped below the base level.

Conclusion

The implementation of the PDMS showed only small effects on documentation of reimbursement-relevant parameters which were too small to set off against the total investment. The method itself, a long-term follow-up of different parameters proved successful and can be adapted by other organizations. The quality of results depends on the availability of long-term parameters in good quality. No significant influence of PDMS on mortality was found.     

Penile venous surgery – prognostic factors and long-term results

Summary Poor longterm success has been reported for penile vein ligation the last few years. Therefore, we decided to re-investigate our group of 147 patients who were operated on between 1987 and 1996. All patients showed a negative response to intracavernous injection therapy at the time of diagnosis and revealed a maintenance flow > 15 ml/min, as well as a pathological venous flow with pharmacocavernosometry or pharmacocavernosography. These patients underwent ligation of all superficial dorsal veins and resection of the deep dorsal vein of the penis. An up-to-date record of the success of the operation was kept either by a renewed clinical visit or by a standardized telephone interview or questionnaire. A total of 126 patients were available here for long-term follow-up. We divided the findings into three groups: complete spontaneous erection, postoperative response to cavernous auto-injection therapy and no changes in erectile competency postoperatively. The short-term success rate for these groups after 1–3 months was an outcome of 31 (24.6 %), 25 (19.8 %) and 70 (55.6 %) patients; 86 % of the cases whose results deteriorated after the initial operation success rate had this happen within the first postoperative year (p K 0.001). Favorable prognostic factors were preoperative erectile dysfunction of K 7 years, a normal CC-EMG and a maintenance flow of K 45 ml/min. If all three parameters were present, the long-term success rate (spontaneous erection plus response to intracavernous injection) of 30 % of all patients was found to rise to 67 % in this selected group of patients (p K 0.001). This study reveals that long-term success for unselected patients undergoing penile venous surgery is disappointing; however, careful selection of patients by certain prognostic factors can improve long-term results.      

Second-line chemotherapy with mitomycin-C and 5-fluorouracil in the treatment of refractory metastatic cancer of the urinary bladder

Summary We performed a phase II trial with second-line chemotherapy in patients with refractory, metastatic cancer of the bladder. Second-line therapy consists of 2.6 cycles of mitomycin-C, 5-fluorouracil and folic acid. Two patients suffered from WHO grade III side effects (nephrotoxicity, leukocytopenia). We did not find any complete or partial remission. Four patients had a stable disease; 3.3 months after therapy, patients developed tumor progression with a median survival of 9 months. Four patients reported an improvement in quality of life. Since all patients received supportive care, improvement in quality of life cannot be related to chemotherapy alone. In conclusion, second-line chemotherapy with mitomycin-C, 5-fluorouracil and folic acid has no effect on refractory, metastatic cancer of the bladder and is no alternative for cisplatin and methotrexate-based chemotherapy.      

Endoscopic controlled splitting of the diaphragm. A minimal invasive approach for the treatment of thoraco-lumbar fractures of the spine

Summary On 90 patients with 93 unstable fractures of the thoracic spine and the thoracolumbar junction we treated by a minimal invasive procedure between may 1996 and april 1998, in 46 patients an endoscopic splitting of the diaphragm was performed. The diaphragma was dissected at its attachment at the spine and the adjoining costal base. After partial corporectomy and discectomy, a tricortical bone graft has been inserted. An additional stabilization was done by using a plate and screw system. The incision of the diaphragm was closed by suturing or using an universal endostapler. Controlling the postoperative results a complete closure of the incision was documented by X-ray and CT-scan. There was no conversion to the open procedure or postoperative infection. Splitting the diaphragma opens also the thoracolumbar junction to a minimal invasive treatment and stabilization of fractures.      

Diagnostic of non-palpable testis in children: laparoscopy or magnetic resonance imaging?

Summary Laparoscopy and magnetic resonance imaging (MRI) are competetive tools in the diagnostic of non-palpable testis. Advantages and disadvantages of this methods will be demonstrate. 29 boys investigated for this indication with MRI. In case MRI failed to locate the testis laparoscopy was performed with a new miniaturized set of pediatric instruments (1.9 mm optic). The aim of laparoscopy was the identification of the spermatic duct and vessels and their topographic relation to the internal inguinal ring. All findings were verified by open surgical procedures. MRI revealed 10 inguinal and 7 abdominal testis. There was no false positive finding. In 12 boys MRI showed no testis. 4 cases were correct negative, 8 cases were false negative (32 %). In these 8 MRI-negative patients laparoscopy revealed 7 inguinal and 1 abdominal testis. The optical quality of the mini-telescope was sufficient for a 100 % correct diagnosis. Laparoscopy related complications did not occur. Laparoscopy proved to be a powerful low risk diagnostic method in non- palpable testis with high senitivity and specifity (100 % correct positive, 0 % false negative). Therefore lapraroscopy is recommended as primary diagnostic access for this indication. In the same anesthesia a optimal therapy is possible. Nevertheless a positive MRI-finding locates the testis reliably, whereas a negative finding always needs further exploration because testis might have been missed.      

Management of case fees and special charges with aid of the coding system “do it”

INTRODUCTION: With the German health care restructuring legislation ("Gesundheitsstrukturgesetz") the coding of diagnoses and operations according to ICD-9 and ICPM (OPS-301) was introduced for budget assignment ("Fallpauschalen/Sonderentgelte"). METHODS: Application of the structured coding system "do it" in orthopedics and traumatology in combination with a surgical documentation system. Results of 8,664 documented operative cases within three years. RESULTS: In total, 11,854 ICD-9 or ICD-10 and 20,178 ICPM (OPS-301) were coded. 2,914 "Fallpauschalen" and/or 3,456 "Sonderentgelte" were found. The System achieved high acceptance due to its userfriendliness and simple functionality. DISCUSSION: In comparison with text- or thesaurus-based coding systems the "do it" coding system does not require any knowledge of the ICD or ICPM (OPS-301). It can be adapted to individual clinical requirements by implementing frequent diagnoses and individual therapy concepts. In combination with a medical information system the coding system can be integrated seamlessly into routine documentation.     

Prevention of thromboembolism in trauma surgery – current jurisdiction

Summary To date, current jurisdiction has not permitted an answer to the Aquestion as to how long thromboembolism prevention therapy is to be carried out after trauma surgery. However, the Bundesgerichtshof (BGH) reached a decision in 1995 on this matter. Accordingly, patients have to be informed about possible alternative treatment as well as the applicable form of thromboembolism prevention therapy in each specific case. In combination with the fact that the Deutsche Gesellschaft für Phlebologie (DGP, German society for phlebology) has published guidelines on thromboembolism prevention therapy via the Internet, this may have considerable impact on the outcome of civil litigation, with consequences for financial compensation. Since civil action requires the medical doctor to prove that he has provided an adequate and acceptable basis for informed consent in patients, in concurrence with the above-mentioned DGP guidelines being potentially misunderstood as representing state-of-the-art treatment, it is deemed necessary to present a list of points that must be brought to the patient's attention when requesting informed consent and, furthermore, the manner in which the guidelines of the medical specialist societies may bring about problems must be pointed out. In the specific context of the German judicial system, criminal law will virtually never lead to a conviction in a case of fatal pulmonary embolism following neglect of or insufficient thromboembolism prevention therapy.      

Scaphoid fracture and scaphoid pseudarthrosis

Summary Careful diagnostic and early therapy are especially important in cases of scaphoid fractures. This is due to the patients being mostly young and the high number of non-unions of these carpal bones. Conservative and various operative treatments are therapeutical options. Out of the patients who underwent surgery from January 1993 to February 1999 42 patients with a scaphoid fracture and 88 patients with a scaphoid non-union were, in addition to standard X-ray examination, examined clinically and by MRI pre- and post-operatively. Fractures of the scaphoid were treated by Herbert screw fixtion. The operative treatment of non- unions of the scaphoid included the transplantation of an iliac crest graft and Herbert screw fixation. Post-operatively a cast-immobilisation was done. Subjective statements of the patients and clinical results were assessed. The classification of Herbert and Fisher (1984)/Filan and Herbert (1996) for X-rays was used. The signal intensities of the MRI in the fragments of the scaphoid were determined qualitatively and quantitatively by computer calculation, comparing the pre- and post-operative results with one another. Post-operative results of the scaphoid fractures were in most cases good and excellent. 67 patients with a scaphoid non-union and 11 with a scaphoid fracture showed a pre-operative diminishing of the signal in the proximal fragment. For these patients, the fusion rate was lower than in patients without pre-operative signal reduction. The examination shows that in most cases bony fusions with good clinical results could be achieved by Herbert screw fixation. The MRI seems to be able to complete the radiological classification of the fractures regarding a prognosis.      

Misleading symptoms after a minor blunt chest trauma

We present a case of missed diaphragmatic rupture which was treated thoracoscopically. Rupture of the diaphragm is a serious complication of blunt trauma. The diaphragmatic injury can easily be overlooked. This report illustrates the diagnostic dilemma in a patient where the injury was missed at the time of initial presentation. The role of thoracoscopy both for diagnosis and therapy is discussed. Received: 24 January 1997/Accepted: 2 April 1997