Assessment of Intraoperative Time for Head and Neck Cancer Surgeries Compared With Medicare Work Time.

PURPOSE: Surgeon reimbursement is dictated in part by the operative time necessary to complete a procedure. The purpose of this study is to compare insurer-set time to true intraoperative time for common head and neck cancer procedures. METHODS: This retrospective cohort study compares intraoperative times between the 2019 Center for Medicare and Medicaid Services (CMS) work-time estimates and the 2017 to 2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data sets for 10 commonly billed head and neck cancer procedures. The primary predictor variable was common head and neck oncologic and reconstructive procedures with corresponding Current Procedural Terminology (CPT) code. The primary outcome variable includes the computed difference between CMS and NSQIP times. Additional variables collected include patient demographics (gender, age, race, and inpatient/outpatient) and work relative value unit (wRVU) per CPT code. Analysis of variance was used to evaluate differences in intraoperative times across CPT codes. Linear regression using standardized coefficients were calculated between CMS time and NSQIP time; CMS time and wRVUs; and NSQIP time and wRVUs. RESULTS: There were 8,330 subjects (44% female, 57.7% inpatient) across 10 CPT codes. Analysis of variance revealed intercode variability in median intraoperative times between CMS and NSQIP (P < .001). CMS underestimated the time necessary to complete excision of malignant tumor mandible (CPT 21045) by 315 minutes. CMS overestimated the time necessary for excision of tongue lesion (CPT 41112) by 5 minutes. Overall, CMS intraoperative time estimates were neither invariably longer nor consistently shorter than NSQIP procedural times (ß, 0.85; 95% confidence interval, 0.43 to 1.26). CONCLUSIONS: CMS estimates of time needed to complete head and neck cancer surgeries varies from national intraoperative times. No consistent trend in underestimation or overestimation of procedure time was found. Improving the accuracy of CMS time estimates used in determining surgeon reimbursement for head and neck cancer procedures may be warranted.

Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopaedic Sports Medicine: A Matched-Pair Analysis.

PURPOSE: To quantify the cost of resident involvement in academic sports medicine by examining differences in operative time, relative value units (RVUs) per case, and RVUs per hour between attending-only cases and cases with resident involvement. METHODS: A retrospective analysis of common sports medicine procedures identified by Current Procedural Terminology code was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2015. Matched cohorts were generated based on demographic variables, comorbidities, preoperative laboratory values, and surgical procedures. Bivariate analysis examined mean differences in operative time, RVUs per case, and RVUs per hour between attending-only cases and cases with resident involvement. A cost analysis was performed to quantify differences in RVUs generated per hour in terms of dollars per case. RESULTS: A total of 14,840 attending-only cases and 2,230 resident-involved cases were used to generate 2 matched cohorts (N = 4,460). Resident cases had greater mean operative times than attending-only cases, with operative time increasing as residents became more senior (P < .01). Residents participated in cases with larger mean RVUs per case (P < .01). Cases with lone attendings showed greater RVUs per hour (P < .01). The cost of resident involvement increased nearly 8-fold from postgraduate year 1 to postgraduate year 6 residents ($25.70 vs $200.07). CONCLUSIONS: In academic sports medicine, the involvement of resident physicians increases operative time. The associated decrease in attending physician efficiency in RVUs per hour equates to an average cost per case of $159.18, with costs increasing as residents become more senior. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Variability in Current Procedural Terminology Codes for Craniomaxillofacial Trauma Reconstruction: A National Survey.

BACKGROUND: Current Procedural Terminology (CPT) codes are an important part of surgical documentation and billing for services provided within the United States. This limited coding language presents a challenge in the heterogenous and rapidly evolving field of craniofacial surgery. The authors aimed to survey members of the American Society of Maxillofacial Surgery (ASMS) to characterize the variability in coding practices in the surgical management of craniofacial trauma. METHODS: A cross-sectional of 500 members of the ASMS survey was carried out. Descriptive statistics were calculated. The effect of various practice characteristics on coding practices was evaluated using Chi-squared tests and Fisher's exact tests. RESULTS: In total, 79 participants responded including 77 plastic surgeons. About 75% worked in academic centers and 38% reported being in practice over 20 years. Coding practices were not significantly associated with training background or years in practice. Unilateral mandibular and unilateral nasoorbitoethmoid fractures demonstrated the greatest agreement with 99% and 88% of respondents agree upon a single coding strategy, respectively. Midface fractures, bilateral nasoorbitoethmoid fractures, and more complex mandibular demonstrated considerable variability in coding. CONCLUSION: There is a wide variability among members of the ASMS in CPT coding practices for the operative management of craniofacial trauma. To more accurately convey the complexity of craniofacial trauma reconstruction to billers and insurance companies, the authors must develop a more descriptive coding language that captures the heterogeneity of patient presentation and surgical procedures.

Variations in Current Procedural Terminology Coding for Craniofacial Surgery: A Need for Review and Change.

BACKGROUND: A survey was utilized to study the coding practices of surgeons performing craniofacial procedures, in order to determine whether coding for these procedures might be standardized or expanded. METHODS: An online survey was designed with 6 sample cases to cover a variety of procedures encountered in the field of craniofacial surgery which was sent to members of 3 professional organizations centered around the practice of craniofacial/maxillofacial surgery. Surgeons were asked to read the vignettes and choose from a series of multiple-choice responses to code the cases, or write in their own response. Codes were based on the American Medical Association current procedural terminology listings. Responses were compiled and tabulated. RESULTS: One hundred twenty-eight people initiated the survey. The largest common coding responses for each vignette were selected by 45.2% of respondents for the case describing placement of an internal mandibular distractor; 45.3% for the case of scaphocephaly remodeling; 67.1% for a case of cranioplasty for trigonocephaly; 47.2% for hypertelorism repair with periorbital osteotomies; 60% for LeFort III advancement with external distractors; and 53.6% for the case describing the removal of an internal mandibular distractor. Between 4 and 12 codes were identified for possible use in each clinical scenario. CONCLUSION: There appears to be wide variability among those who routinely perform craniofacial surgery as to the appropriate ways to code these procedures. We hope to bring this to the attention of coding committees for further discussion to hopefully bring about more accurate and descriptive codes for craniofacial surgical procedures.

2014 Edition Electronic Health Record certification criteria: revision to the definition of "common Meaningful Use (MU) Data Set." Interim final rule with comment period.

This interim final rule with comment period revises one paragraph in the Common Meaningful Use (MU) Data Set definition at 45 CFR 170.102 to allow more flexibility with respect to the representation of dental procedures data for electronic health record (EHR) technology testing and certification.

Temporomandibular disorders/myoarthropathy of the masticatory system. Costs of dental treatment and reimbursement by Swiss federal insurance agencies according to the Health Care Benefits Ordinance (KLV).

The goal of the study was to calculate the direct costs of therapy for patients with MAP. This retrospective study included 242 MAP patients treated at the Department of Prosthodontics of the University of Bern between 2003 and 2006. The following parameters were collected from the clinical charts: chief complaint, diagnosis, treatment modalities, total costs, costs of the dental technician, number of appointments, average cost per appointment, length of treatment, and services reimbursed by health insurance agencies. The average age of the patients was 40.4 ± 17.3 years (76.4% women, 23.6% men). The chief complaint was pain in 91.3% of the cases, TMJ noises (61.2%) or limitation of mandibular mobility (53.3%). Tendomyopathy (22.3%), disc displacement (22.4%), or a combination of the two (37.6%) were more often diagnosed than arthropathy alone (7.4%). Furthermore, 10.3% of the MAP patients had another primary diagnosis (tumor, trauma, etc.). Patients were treated with counseling and exercises (36.0%), physiotherapy (23.6%), or occlusal splints (32.6%). The cost of treatment reached 644 Swiss francs for four appointments spread over an average of 21 weeks. In the great majority of cases, patients can be treated with inexpensive modalities. 99.9% of the MAP cases submitted to the insurance agencies were reimbursed by them, in accordance with Article 17d1-3 of the Swiss Health Care Benefits Ordinance (KLV) and Article 25 of the Federal Health Insurance Act (KVG). The costs of treatment performed by dentists remain modest. The more time-consuming services, such as providing information, counseling and instructions, are poorly remunerated. This aspect should be re-evaluated in a future revision of the tariff schedule.

A review of bioactive materials and chronic wounds.

An increasing number of bioactive materials are indicated for the treatment of chronic lower extremity ulcers. They are promising adjuncts to standard therapy. When used in conjunction with standard therapy for venous leg ulcers and diabetic foot ulcers, bioactive materials may increase the likelihood and rate of healing. This review compares commonly available bioactive materials indicated for chronic wound healing and provides an overview of the relevant Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for these products.

Role and models for compensation of tobacco use prevention and cessation by oral health professionals.

Appropriate compensation of tobacco use prevention and cessation (TUPAC) would give oral health professionals better incentives to provide TUPAC, which is considered part of their professional and ethical responsibility and improves quality of care. Barriers for compensation are that tobacco addiction is not recognised as a chronic disease but rather as a behavioural disorder or merely as a risk factor for other diseases. TUPAC-related compensation should be available to oral health professionals, be in appropriate relation to other dental therapeutic interventions and should not be funded from existing oral health care budgets alone. We recommend modifying existing treatment and billing codes or creating new codes for TUPAC. Furthermore, we suggest a four-staged model for TUPAC compensation. Stages 1 and 2 are basic care, stage 3 is intermediate care and stage 4 is advanced care. Proceeding from stage 1 to other stages may happen immediately or over many years. Stage 1: Identification and documentation of tobacco use is part of each patient's medical history and included into oral examination with no extra compensation. Stage 2: Brief intervention consists of a motivational interview and providing information about existing support. This stage should be coded/reimbursed as a short preventive intervention similar to other advice for oral care. Stage 3: Intermediate care consists of a motivational interview, assessment of tobacco dependency, informing about possible support and pharmacotherapy, if appropriate. This stage should be coded as preventive intervention similar to an oral hygiene instruction. Stage 4: Advanced care. Treatment codes should be created for advanced interventions by oral health professionals with adequate qualification. Interventions should follow established guidelines and use the most cost-effective approaches.

Pay for performance: will dentistry follow?

BACKGROUND: "Pay for performance" is an incentive system that has been gaining acceptance in medicine and is currently being considered for implementation in dentistry. However, it remains unclear whether pay for performance can effect significant and lasting changes in provider behavior and quality of care. Provider acceptance will likely increase if pay for performance programs reward true quality. Therefore, we adopted a quality-oriented approach in reviewing those factors which could influence whether it will be embraced by the dental profession. DISCUSSION: The factors contributing to the adoption of value-based purchasing were categorized according to the Donabedian quality of care framework. We identified the dental insurance market, the dental profession position, the organization of dental practice, and the dental patient involvement as structural factors influencing the way dental care is practiced and paid for. After considering variations in dental care and the early stage of development for evidence-based dentistry, the scarcity of outcome indicators, lack of clinical markers, inconsistent use of diagnostic codes and scarcity of electronic dental records, we concluded that, for pay for performance programs to be successfully implemented in dentistry, the dental profession and health services researchers should: 1) expand the knowledge base; 2) increase considerably evidence-based clinical guidelines; and 3) create evidence-based performance measures tied to existing clinical practice guidelines. SUMMARY: In this paper, we explored factors that would influence the adoption of value-based purchasing programs in dentistry. Although none of these factors were essential deterrents for the implementation of pay for performance programs in medicine, the aggregate seems to indicate that significant changes are needed before this type of program could be considered a realistic option in dentistry.

Scope of practice comparison: a tool for curriculum decision making.

The proportion of claims filed for specific dental procedures (ADA codes # 05110, 05120, 03320, 03330, 04260, 02150) between January 1, 2000 and June 30, 2004 by Texas general practitioners participating in a preferred provider network was compared to the proportion of these procedures performed by students graduating from the three Texas dental schools during the same period. Analysis of the data revealed that Texas dental students provide class two amalgam restorations in permanent teeth (02150) at approximately the same frequency as Texas general practitioners. Both groups provide periodontal osseous surgery (04260) at an extremely low frequency (<0.02% of total procedures). Bicuspid endodontic procedures (03320) were performed at a slightly higher frequency by students (0.43% of all procedures) than by general practitioners (0.36% of all procedures), and molar endodontic procedures (03330) were performed at a slightly higher frequency by general practitioners (0.65%) than by students (0.36%). Significant discrepancies between the groups were noted for the two complete denture procedures (05110, 05120). Students provided these procedures at frequencies fifteen times (05110) and twenty-five times (05120) greater than general practitioners. Dental schools should use data provided by scope of practice analyses to help determine an appropriate breadth and depth for their educational programs.

The ins and outs of dental insurance.

BACKGROUND: In the past three decades, dental insurance has become a permanent fixture in the delivery of dental services. Some would argue that this has not been good for dentists. However, none will dispute that it is here to stay and that dentists must make some very important decisions in their practices with regard to dental insurance. This article will explore some of those decisions and offer some guidance on how to decide wisely. CONCLUSIONS: Dental insurance now is a permanent fixture in the delivery of dental care. Each dentist must decide if participation with a dental insurance company is in his or her best interest. To make this decision, a dentist must have as much information as possible to evaluate each specific dental plan. If a dentist does decide to participate, the dentist must know the rules. PRACTICE IMPLICATIONS: Participation with a dental insurance company may influence the dentist-patient relationship. Dentists must be prepared to answer the question, "Why do I need this service if my dental insurance does not cover it?" Non-participation with a dental insurance company may result in a reduced number of new patients.

Reimbursement for dental implants: dispelling some popular myths.

BACKGROUND AND OVERVIEW: Dental implants are being placed with increasing regularity. Many dentists do not take advantage of insurance coverages for this treatment because they are under the impression that no aspect of implant therapy is covered. This article discusses a number of insurance benefits that may be available to dental patients but not readily apparent to treating dentists and their staff members. CONCLUSIONS AND PRACTICE IMPLICATIONS: Some dentists and patients may assume incorrectly that a dental insurance plan does not reimburse for any implant therapy when, in fact, there may be some benefit available for at least a portion of the treatment. In addition, some dentists and patients may not consider implant therapy even when it is the preferred treatment option because of the assumed lack of reimbursement. Knowing that some reimbursement is available may make the difference in the patient's accepting the best treatment for his or her condition. Furthermore, since an increasing number of patients now make some contribution toward their dental insurance plan premiums, they deserve to know their options and to receive appropriate benefits.

Continuing education: insurance cross coding: submitting medical insurance.

This continuing education course is designed for general dentists, dental hygienists, dental assistants, and office managers. This continuing education course will provide general information pertaining to the reporting of dental services to medical third parties. An office protocol outlining the steps necessary to file medical insurance claims for dental treatment will serve as a guide in the management of third party payment.

The Health Insurance Portability and Accountability Act and the practice of dentistry in the United States: electronic transactions.

This article reviews the kinds of electronic transactions required under the Health Insurance Portability & Accountability Act (HIPAA) and relates them to relevant data contained in an electronic oral health record (EOHR). It also outlines the structure of HIPAA transactions using the claim transaction as an example. The relationship of the HIPAA resource management function to those of patient care are discussed. The discussion points out potential future uses of other existing resource management transactions to realize the maximum potential of linking the primary patient care functions to those functions related to managing resources in support of that care. This is needed in all aspects of oral health using the informatics standards activities in which the American Dental Association (ADA) actively participates. The article concludes by providing the dentist a perspective on how to relate these capabilities to his/her individual practice setting.

The Health Insurance Portability and Accountability Act: practice of dentistry in the United States: privacy and confidentiality.

This paper introduces the reader to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 legislation in the context of its relationship to the Electronic Oral Health Record (EOHR). Privacy and confidentiality issues for administrative data are addressed in terms of the broader relationship of such data to the EOHR leaving the HIPAA-defined administrative transactions and security issues for the entire practice for a subsequent presentation. Educational requirements are presented that aid the dentist and the practice staff in understanding the broad and long-term implications of the HIPAA legislation.