Current Procedural Terminology Research Articles

Conformal Prediction and Large Language Models for Medical Coding

Abstract The assignment of current procedure terminology (CPT) codes to medical events is a highly cumbersome, logistic challenge for many healthcare organizations, as well as a significant contributor to medical expenses. Improvement in the allocation of medical resources and expenses dedicated to such tasks can be achieved through automation. However, because of the complex nature of medical records, automation of procedure terminologies is just now developing with the advent of machine learning methods. In this study, we develop a fine-tuned large language model (LLaMA-3B) as a high-reliability predictor for CPT codes. As input, we use 2018 pathology report text data, including gross report, microscopic description, brief medical history, and final diagnosis. We define our dataset with the top five most common technical component CPT codes, which account for 85% of all samples. As a (meta) predictor of the veracity of the large language model itself, we use the prediction’s softmax scalar value of the classification model, borrowing from similar recent approaches in conformal prediction. Specifically, the validation set, which is distinct from both the train and test set, is used to establish a prediction threshold below which the model withholds judgement. We show that, by fine tuning an off-the-shelf language model on pathology report text alone, we can achieve 95% prediction accuracy of the top 5 most common CPT codes on our dataset. We also then demonstrate the utility of combining large language models with conformal prediction. The two in combination raise our accuracy to 99.5% when we allow the model to abstain on making a prediction on 30% of the data, as is determined by a separate threshold on the scalar value of the predictor from the aforementioned validation set. We therefore present a highly flexible model for medical coding, which is simultaneously provably-reliable. Large language models can as such serve as a powerful tool for overcoming challenges in medical billing, thereby improving healthcare efficiency and reducing medical costs.

A Data-Driven Approach to Inguinal Hernia Repairs in Infants and Children.

Introduction: Laparoscopic inguinal hernia repair has become increasingly popular in children. The laparoscopic technique inherently assesses the contralateral processus vaginalis, reducing the risk of metachronous contralateral hernias. We hypothesized that primary laparoscopic repair would be associated with lower rates of subsequent hernia repair in the youngest patients, in whom metachronous contralateral hernias are most common. Materials and Methods: The Pediatric Health Information System database was queried for patients 0-15 years old, who underwent inguinal hernia repair between 2016 and 2022. The primary outcome was the need for subsequent hernia repair. Current Procedural Terminology (CPT) and ICD-10 procedure codes were used to determine laparoscopic versus open repair. Patients were excluded if the only recorded code was for recurrent hernia or if both laparoscopic and open codes were present for the same procedure. Results: A total of 109,456 patients were included in the study, with 20,338 patients (18.58%), undergoing laparoscopic inguinal hernia repair initially, and 2535 patients (2.32%) requiring a second hernia repair. Patients 6 months old and younger undergoing unilateral laparoscopic repair were less likely to require subsequent surgery (OR 0.82, 95% CI = 0.69-0.96). Across all ages, open bilateral repair less often required subsequent repairs (OR 1.93, 95% CI 1.48-2.51). Conclusion: Laparoscopic unilateral inguinal hernia repair decreases the need for subsequent surgical repair in infants 6 months and younger. No difference was detected in older patients. Open repair of bilateral hernias decreases the need for a second hernia operation in all age groups, suggesting that open repair is more durable.

Resurgent Inflation and its Impact on Medicare Reimbursements for Outpatient Gastroenterology Procedures.

Rising healthcare costs have led to decreasing reimbursements for various procedures and providers. We chose to analyze Medicare reimbursement trends for 26 esophagogastroduodenoscopy (EGD) and 31 colonoscopy current procedural terminology (CPT) codes from 2018 to 2023 for hospital outpatient centers, ambulatory surgical centers and gastroenterologists. We also wanted to look at the effects of inflation on these Medicare reimbursements. We calculated the nominal percentage change from 2018 to 2023 for each CPT code. We then took inflation data provided by the U.S. Bureau of Labor Statistics and calculated the real change in reimbursements from 2018 to 2023 for each of the 31 colonoscopy and 26 EGD CPT codes. Our results show that while nominal reimbursements to physicians have been steadily declining for performing gastrointestinal procedures, nominal reimbursements to hospital outpatient and ambulatory surgical centers have been increasing from 2018 to 2023. After taking into account inflation, physicians saw significant decreases in real purchasing power for performing EGD and colonoscopies. Ambulatory surgical centers and hospital outpatient centers saw reimbursements keep up with inflation. Physician reimbursements by Medicare for gastroenterology procedures make up a small portion of the reimbursements by Medicare to facilities like ambulatory surgical centers and hospital outpatient centers. However physicians have seen significant reimbursement cuts while facilities have not. Moreover, higher inflation leads to increased expenses for gastroenterology practices. It remains to be seen how these reimbursement changes will affect patients access to care as well as physicians practice sustainability.

Cost Drivers of Pars Plana Vitrectomy for Retinal Detachment: Time-Driven Activity-Based Costing Analysis.

Introduction: To determine drivers of day-of-surgery costs for pars plana vitrectomy (PPV) in the management of retinal detachment (RD) repair, the mainstay treatment, based on surgical complexity and intraoperative factors. Methods: Economic analysis was performed using time-driven activity-based costing methodology for patients who had standard (Current Procedural Terminology [CPT] code 67108) or complex (CPT 67113) RD repair with PPV at the University of Michigan in 2021. Data were obtained via the electronic health record and previous literature. PPV expenses were determined with time-driven activity-based costing, a cost calculation that incorporates time and key resource costs, and were analyzed using univariate and multivariate regression. Results: The analysis included 412 PPVs (270 standard and 142 complex based on CPT code). The operating room time was significantly increased in complex cases (P < .01). Univariate analysis found that complex PPV, cryopexy, staining agent use, retinectomy, simultaneous scleral buckling, perfluoro-N-octane (PFO) use, silicone oil tamponade, and perfluoropropane tamponade were associated with a statistically significant difference in costs (P < .01); use of laser retinopexy was not significantly associated (P = .7190). Multivariate analysis found that standard PPV cost an average $5132.33 and significant incremental costs were found for complex PPV (+$1185.55; P < .001), cryopexy (+$465.02; P = .032), staining (+$525.16; P = .04), PFO use (+$1089.54; P < .0001), retinectomy (+$2031.17; P < .0001), and simultaneous scleral buckling (+$916.34; P = .006). Conclusions: The intraoperative factors that increase operating room time and ultimately the incurred cost of complex PPV cases vs standard PPV were identified and economically defined. These findings can improve practice patterns by optimizing costs for effective surgical planning in the management of RD repair.

Impact of 2023 Ventral Hernia Repair CPT Code Changes on Work Relative Value Units in a Tertiary Hernia Referral Center.

CPT codes for ventral hernia repair (VHR) changed in January 2023 to address the heterogeneity of procedures with a concomitant shift from a 90-day to a 0-day global period. This study reviews a tertiary referral center's experience with hernia coding comparing the work relative value units (wRVUs) generated for ventral hernia repair pre-2023 compared to post-2023. CPT codes were analyzed for patients undergoing open or laparoscopic VHR before updates to the CPT hernia codes (January 2022-September 2022) and following CPT change (January 2023-September 2023). Work RVU values were assigned based on nationally published values. CPT codes in 2022, CPT codes in 2023, 8 inpatient E&M codes, and 5 outpatient E&M codes were evaluated. 299 patients underwent VHR, 143 in 2022 and 156 in 2023. Average procedural VHR wRVUs increased from 9.6 in 2022 to 11.6 in 2023 (p<0.001). Procedures involving myofascial advancement flaps/component separation techniques (53.8% vs. 48.7%, p = 0.419) and wRVUs for the component separation procedures were similar between 2022 and 2023, respectively 17.7 vs 16.1 (p=0.419)]. The wRVUs associated with adjunctive procedures (mesh removal/placement) decreased from 3.3 to 0.6 (p<0.001) in the post-2023 era. Postoperative E&M wRVUs increased in 2023 for postoperative inpatient (0.48) and postoperative outpatient (0.39) services, compared to 0 wRVUs in 2022. Overall, the total management including follow-up clinic visit adjusted wRVUs for hernia repair was similar between 2022 and 2023, respectively 30.7 vs 29.2 (p=0.409). Procedural wRVUs for anterior abdominal hernia repair increased from 2022 to 2023 (p<0.001) at a tertiary referral medical center. However, total wRVUs, including the operation and postoperative visits, remained unchanged.

Increasing Utilization of Intratympanic Injections among Medicare Fee-for-Service Providers.

To characterize national practice patterns and geographic variations in intratympanic injections among Medicare providers. Retrospective cross-sectional analysis of intratympanic injections performed in the Medicare fee-for-service population from 2013 to 2021. Center for Medicare & Medicaid Services Physician and Other Practitioners database. Providers performing outpatient intratympanic injections, documented by Current Procedural Terminology code 69801. Intratympanic injections. The number of intratympanic injections performed by individual providers, states, and geographic regions, as well as reimbursements, was analyzed annually. A total of 159,236 in-office intratympanic injections were performed. The Center for Medicare & Medicaid Services reimbursed $25,407,086; out-of-pocket patient costs were $6,591,514. The mean Medicare reimbursement rate and out-of-pocket cost per injection were $159.56 and $41.38, respectively. From 2013 to 2021, the number of intratympanic injections increased from 13,117 to 20,711 injections, representing a 57.9% increase. On linear regression, an additional 989.9 injections were performed each year (95% CI 766.4-1,213.4, p < 0.001). The number of providers performing injections also increased from 1,828 to 2,834 from 2013 to 2021 (b = 125.6 [95% CI 111.3-140.0], p < 0.001). The population-controlled annual mean number of injections varied substantially across the United States, ranging from 12.0 injections per 100,000 beneficiaries in Oklahoma to 255.2 injections per 100,000 beneficiaries in Alabama. The number of intratympanic injections administered in the Medicare population has increased from 2013 to 2021. There is variability in practice patterns and utilization of intratympanic injections among otolaryngologists in the United States.

Utilization of Remote Patient Monitoring for Neurological Disorders: A Nationwide Analysis of Administrative Claims Data.

Introduction: The use of remote patient monitoring (RPM) services for neurological disorders remains understudied, particularly in the context of newer billing codes introduced before the COVID-19 pandemic. Methods: This retrospective cohort study utilized data from commercial and Medicare employer-sponsored administrative claims between January 1, 2019, to December 31, 2021. The study population included all patients with at least one qualifying RPM-related Current Procedural Terminology (CPT) code for a neurological disorder, separated into first-generation (CPT 99091) codes and second-generation (CPT 99453, 99454, 99457, 99458) code cohorts. We compared patient and encounter characteristics between both cohorts. Results: We identified 27,756 encounters attributable to 11,326 patients who received RPM services for neurological disorders, of whom 5,785 (51.1%) received RPM via second-generation billing codes, 3,941 (34.8%) were female, 6,712 (59.3%) were between 45 and 64 years old, and 10,488 (92.6%) had a primary diagnosis of sleep-wake disorder. The second-generation cohort was significantly more likely to be female (41.5% vs. 27.8%, p < 0.001), be of age 65 or older (15.7% vs. 7.1%, p < 0.001), and reside in urban areas (93.4% vs. 87.6%, p < 0.001) than the first-generation cohort. Patients in the second-generation cohort were more likely to receive RPM in office settings (86.3% vs. 62.5%, p < 0.001), by physicians (77.0% vs. 40.3%, p < 0.001), and less likely for sleep-wake disorders (87.9% vs. 97.5%, p < 0.001) than the first-generation cohort. Patients who received RPM from physicians were most often evaluated by pulmonologists (31.4%). Discussion: In this commercially insured patient population receiving RPM for neurological disorders, we found that sleep-wake disorders and non-neurologists were over-represented.

7706 Racial Disparities in Thyroid-Related Procedure Reoperation Rates: Insights from NSQIP Database

Abstract Disclosure: H.A. Erol: None. A. Liu: None. K. Wardwell: None. S. Woodruff: None. Background: Racial disparities in health outcomes are well-documented, with specific conditions affecting racial groups differently. However, the influence of race on endocrine surgery outcomes remains an evolving field of study. This research seeks to evaluate the effect of race on unplanned reoperations using the National Surgical Quality Improvement Program(NSQIP)-database and to investigate additional risk factors for reoperations in this cohort. Methods: We analyzed the NSQIP-database for thyroid-related procedures from 2012-2021 using CPT codes. Patient demographics, including age, sex, height/weight, ASA classification, and comorbid conditions, were assessed for unplanned reoperations. Univariate, multivariable logistic regression, and adjusted residual analyses were conducted assessing individual variables, adjusted odds ratios(ORs), and for post-hoc analyses. Results: Over the 10-year period, 169,251 patients were identified, with an overall reoperation incidence of 1.32%. Univariate analysis revealed that race correlated with increased reoperation rates, with the highest incidence observed among American Indian/Alaska Native (2.13%) patients, followed by Native Hawaiian/Pacific Islander (1.93%), Black/African American(1.84%), White (1.22%), and Asian(1.08%) patients. In multivariate logistic regression analysis, Black/African American (OR 1.452, 95% CI 1.293-1.630, p &amp;lt; 0.001) and American Indian/Alaska Native (OR 1.775, 95% CI 1.039-3.031, p = 0.036) patients had a higher risk of reoperation compared to White patients. Other factors associated with increased reoperation risk included male gender, higher ASA class, smoking, partially dependent functional status, ventilator dependency, hypertension, dialysis, disseminated cancer, bleeding disorders, and systemic inflammatory response syndrome or sepsis. Most reoperations were hematoma related(63.02%), with statistical significance noted among different ethnicities and types of reoperations. White patients had lower rates of hematoma-related procedures, fewer tracheostomies, and more additional thyroid procedures. Black/African American patients had more tracheostomies and fewer lymphatic-related or additional thyroid procedures. Conclusions: Using the NSQIP-database, Black/African American and American Indian/Alaska Native patients were at a greater risk of reoperation following thyroid surgeries, even after accounting for multiple variables. Black/African American patients also had disparate types of reoperations. These findings highlight the impact of race on thyroidectomy-related outcomes. Further research is imperative to comprehensively understand the role of race in surgical outcomes and to address healthcare disparities and inequities. Presentation: 6/2/2024

Associations Between Short-Term Postoperative Outcomes and Immunocompromised Status in Patients Undergoing Sacrocolpopexy.

Few data exist on the impact of immunosuppression on perioperative outcomes in women undergoing sacrocolpopexy. The objective of this study was to compare differences in 30-day perioperative morbidity in immunocompromised versus non-immunocompromised women undergoing sacrocolpopexy (SCP). We hypothesize that compared with the non-immunocompromised group, immunocompromised women undergoing SCP experience worse composite 30-day postoperative outcomes. Retrospective cohort of female patients aged 18years or older who underwent sacrocolpopexy from 2012 to 2017. Current procedural terminology (CPT) codes 57280 and 57425 identified sacrocolpopexy in the American College of Surgeons-National Surgical Quality Improvement Project database. The primary exposure was a binary indicator of immunocompromised status, and the primary outcome was a composite indicator of readmission, reoperation, or a severe adverse event 30days after surgery. Marginal standardization, a G-computation method, was used to estimate risk ratios (RR) and 95% confidence intervals (CI) representing the association between exposure and outcome. A total of 13,505 women underwent SCP between 2012 and 2017. Of those, 2,625 (19.4%) had an indicator of immunocompromised status, with diabetes and smoking being most common. The risk of the composite adverse outcome in immunocompromised women was 7.3% versus 4.6% in non-immunocompromised women. After adjusting for age, race, ethnicity, and body mass index, immunocompromised women experienced 54% increased relative risk of an adverse outcome, compared with non-immunocompromised women (RR = 1.54; 95% CI: 1.31, 1.82). Immunocompromised status, most commonly caused by diabetes and smoking, increases the risk of readmission, reoperation, and a severe adverse event within 30days of sacrocolpopexy.

Differences in Primary Total Shoulder Arthroplasty Volume, Reimbursement, Practice Styles, and Patient Populations Based on Surgeon Gender: A Temporal Analysis

BackgroundOrthopedic surgery has previously been shown to have a shortage of female physicians and a gender pay gap. However, this has not been thoroughly evaluated in the setting of shoulder surgery. The primary purpose of this study was to evaluate differences in total shoulder arthroplasty (TSA) volume, reimbursement, surgeon billing practices, and patient populations between male and female surgeons from 2013 to 2021. MethodsThe Medicare Physician and Other Practitioners database, a publicly available dataset that includes 100% of services billed to Medicare Part B was utilized. The database was queried for all billing episodes of Current Procedural Terminology (CPT) code 23472, which encompasses both anatomic and reverse primary TSA. Procedural volume, average inflation-adjusted reimbursement per TSA, physician billing information, and the patient demographics of each surgeon who performed TSAs were collected. Welch’s t-test and Kruskal-Wallis were utilized to compare male and female surgeons each year between 2013 and 2021. ResultsBetween 2013 and 2021, the proportion of TSAs performed by female surgeons nationally increased from 1.8% to 2.9% (+1.1%). This increase was greatest in the Northeast (2.0% to 6.1%), while a decrease was seen in the Midwest (1.9% to 1.6%). In 2021, there was no significant difference between male and female surgeons in the average inflation-adjusted reimbursement per TSA ($1,144.00 vs $1,143.00, p=0.792) and the average number of TSAs performed per surgeon (26.6 vs 23.1, p=0.105). Female TSA surgeons, on average, had less Medicare beneficiaries (348 vs 462, p<0.001), performed fewer annual services (1,817 vs 3,630, p<0.001), and performed fewer unique services (60 vs 76, p<0.001) compared to male surgeons. A higher proportion of female surgeon’s patient populations were non-White (24% vs 22%, p=0.028), female (61% vs 59%, p=0.001), and dual enrolled Medicare-Medicaid patients (13% vs 10%, p<0.001). However, there was no difference in the average patient complexity between male and female TSA surgeons based on hierarchical condition category (HCC) score (1.0783 vs 1.0732, p=0.228). ConclusionFemale representation within TSA surgery is increasing nationally, with the greatest representation in the Northeast and West and the lowest representation in the South and Midwest. Although female TSA surgeons perform a similar number of TSAs, receive comparable reimbursement per TSA, and have a similarly complex patient population as their male counterparts, they perform significantly fewer total and unique billable services annually. Additionally, female TSA surgeons tend to see more non-White, women, and dual Medicare-Medicaid enrolled patients.

Long-Term Clinical Outcomes Following the WATCHMAN Device Use in Medicare Beneficiaries.

Long-term outcomes following left atrial appendage occlusion outside clinical trials and small registries are largely unknown. Collecting these data was a condition of US market authorization of the WATCHMAN device. The aim of this analysis was to evaluate the rates of stroke, bleeding, and death among Medicare beneficiaries following left atrial appendage occlusion implantation during initial commercial availability of the WATCHMAN left atrial appendage occlusion device overall and in important subgroups. All Medicare fee-for-service beneficiaries ≥65 years of age who underwent left atrial appendage occlusion from April 1, 2016, to August 31, 2020, were included based on the International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes. Over a 5-year follow-up period, the cumulative incidence over time of mortality, ischemic stroke, and major bleeding were calculated using the International Classification of Diseases, Tenth Revision, diagnosis codes for the full study cohort and within important prespecified subgroups. WATCHMAN recipients (n=48 763) were a median of 77 (interquartile range, 72-82) years of age, 42% female, and mostly White (93%). The median CHA2DS2VASc score was 4 (interquartile range, 3-5) with prior major bleeding in 42% and prior stroke in 12%. At 5 years, death occurred in 44%, bleeding in 15% (with higher risk early following implantation), and ischemic stroke in 7%. Each of these end points was more common with greater baseline age. Male patients had greater 5-year mortality than female patients (46.9% versus 40.6%), but there was no difference between sexes in the rates of ischemic stroke (6.6% versus 7.5%) or major bleeding (14.9% for both). WATCHMAN recipients with prior ischemic stroke or a major bleeding event were older and frailer; these groups had higher rates of ischemic stroke, major bleeding, and death. Compared with patients enrolled in the pivotal clinical trials, Medicare beneficiaries undergoing WATCHMAN implantation were older, more female, and had more comorbid conditions. Substantial long-term mortality and major bleeding following WATCHMAN reflect the high-risk nature of the patient population, while the ischemic stroke rate was relatively low (<1.5% per year).

Postoperative Complications in Lingual Versus Palatine Tonsillectomies.

The aim of this study was to investigate the risks of lingual tonsillectomy (LT) in a large cohort and compare these risks to those of palatine tonsillectomy (PT). A retrospective cohort study was conducted using data from the United States collaborative network within TriNetX. The LT group was defined using Current Procedural Terminology (CPT) code 42870 and PT group using CPT codes 42820, 42821, 42825, or 42826. Groups were further subdivided into pediatric and adult populations and matched based on propensity scores within the cohorts. Complications occurring within 14 days of procedure were compared within each cohort. There were 1,357 adult patients (mean age, 42.9 years) and 863 pediatric patients (mean age, 8.1 years). Adults who had LT were more likely to experience postoperative dysphagia (OR = 2.6, p < 0.001) and require admission to the hospital (OR = 4.3, p < 0.001) or intensive care unit (OR = 6.1, p < 0.001). There was no significant difference in bleeding between adult PT and LT groups, occurring at rates of 3.8% and 4.4%, respectively (p = 0.50). Pediatric patients who had LT were also more likely to experience postoperative dysphagia (OR = 2.4, p = 0.017) and require admission to the hospital (OR = 8.2, p < 0.001) or intensive care unit (OR = 2.7, p = 0.012). The postoperative bleed rate was 3.2% in the pediatric PT cohort, which was 2.4 times higher compared to those who underwent LT (1.5%, p = 0.016). Postoperative complications after lingual tonsillectomy are more common than after palatine tonsillectomy in both adults and children. III Laryngoscope, 2024.

A-236 Rapid multiplexed PCR (polymerase chain reaction) tests for respiratory disease improve process and time to diagnosis versus laboratory-based molecular testing

Abstract Background The Infectious Disease Society of America recommends molecular testing for symptomatic patients suspected of having COVID-19. Molecular tests can be performed at the point of care or in a centralized laboratory, using different methodologies, and can be singleplex or multiplex. Limited data are available examining the use of these tests in clinical practice and impact of different test types on patient outcomes; however, common antiviral treatments for both COVID-19 and influenza are more effective when taken earlier and are not indicated for use more than 5 and 2 days after symptom onset, respectively. The aim of this study was to describe the diagnostic journey for non-inpatients who received molecular testing for respiratory pathogens in the laboratory versus those who received testing using a rapid, multiplexed real-time RT-PCR test that can be performed at the point of care. Methods De-identified administrative claims were analyzed from July 1, 2020 through September 30, 2022 for commercially insured and Medicare Advantage enrollees in the Optum Labs Data Warehouse. Patients with ≥1 medical claim for a non-inpatient visit with a procedure code for testing for SARS-CoV-2 were identified; patients who received antigen testing at index were excluded. Patients were followed for up to 90 days. Two patient groups were selected for the final study sample: 1) Patients with ≥1 claim with CPT code 0240U or 0241U with a point-of-care or laboratory place of service on the index date (proprietary laboratory analyses codes for Xpert® Xpress CoV-2/Flu/RSV, or “Xpert Xpress”); and 2) Patients with other laboratory-based molecular testing on the index date. Standardized difference of &amp;gt;0.10 or &amp;lt;-0.10 was considered a significant imbalance in proportions or means. Results In total, 51,602 patients received testing with Xpert Xpress while 317,192 received laboratory testing. Patients who were tested with Xpert Xpress were significantly older (mean 49.82 vs 42.19, SD 0.3), had a higher Charlson Comorbidity Index (mean 0.7 vs 0.35, SD 0.29), and were more likely to have a respiratory risk factor (6.09% vs 2.38%, SD 0.19). On average, patients who were tested with Xpert Xpress had significantly fewer tests for SARS-CoV-2 on the index date (mean 1.2 vs 1.58, SD -0.55), and fewer tests for SARS-CoV-2, influenza, or RSV on the index date and through the end of the 90-day fixed follow-up period (mean 1.64 vs 2.57, SD -0.45). They were also significantly more likely to be diagnosed with COVID-19 on the index date (23.31% vs 16.53%, SD 0.17). Among patients with a diagnosis for COVID-19, mean time to diagnosis was significantly shorter among patients tested with Xpert Xpress (4.85 vs 8.86 days, SD -0.27; median 0 vs 4 days). This finding was also consistent for influenza (4.05 vs 20.28 days, SD -0.74; median 0 vs 5 days). Conclusions Testing with Xpert Xpress at index resulted in fewer total tests and faster diagnosis compared to testing in the laboratory. Rapid, multiplex PCR testing provides a faster time to diagnosis and may support more appropriate and effective treatment.

Reverse Shoulder Arthroplasty for Proximal Humerus Fractures and Reverse Shoulder Arthroplasty for Elective Indications Should Have Separate Current Procedural Terminology (CPT) Codes

BackgroundReverse shoulder arthroplasty (RSA) for fracture currently shares a single current procedural terminology (CPT) code with RSA for arthropathy despite potential differences in patient factors, procedural demands, postoperative care and needs, and overall hospital systems’ resource utilization. We hypothesize that patients indicated for RSA for fracture will have greater medical complexity, require longer operative duration, have higher complication rates, demonstrate inferior functional outcomes, and require greater healthcare cost expenditures compared to a cohort undergoing RSA for rotator cuff arthropathy. Methods383 RSAs were retrospectively reviewed from January 2011 to December 2020. Demographics, comorbidities, operative time, financial charge and cost data, length of stay (LOS), discharge disposition, and all-cause revisions were assessed. Visual analog scale (VAS) pain score and active range of motion (AROM) were evaluated at 2, 6, and 12 months postoperatively. Results197 total RSA were included with 28 for fracture and 169 for arthropathy indications after exclusions. RSA operative time was longer for fractures with an average of 143.2±33.7 minutes compared to 108.2±33.9 minutes for arthropathy (p=0.001). Average cost per patient for RSA for proximal humerus fracture was $2,489 greater than cost for RSA for elective indications; however, no statistically significant difference was noted between average costs (p=0.126). LOS was longer for RSA for fracture compared to arthropathy with a mean of 4.0 ± 3.6 days versus 1.8 ± 2.3 days (p=0.004). The fracture group was 3.6 times more likely to be discharged to a skilled nursing facility or inpatient rehab (32% versus 9%, p=0.002). Early and late all-cause revisions were similar between groups. Differences in postoperative AROM for fracture versus arthropathy were significant for active forward flexion (aFF) at 2 months (95.5±36.7°, 117.0±32.3°) and 6 months (110.9±35.2°, 129.2±28.3°) (p=0.020) as well as active adducted external rotation (aER) at 6 months (20.0±20.9°, 33.1±12.3°) (p=0.007) and at 12 months (23.3±18.1°, 34.5±13.8°) (p=0.012). No difference in VAS pain scores were noted between fracture and arthropathy groups at any time point. DiscussionRSA for fractures versus arthropathy have substantial differences in patient characteristics, surgical complexity, and hospital resource utilization. This is of importance given the currently available CPT code does not differentiate indications for RSA, especially if intending to accurately document surgical care delivered.

Enoxaparin and Early Postoperative Tibial Nailing: Increased Nonunion Revision Rates.

To determine the association between postoperative enoxaparin use and the risk of requiring surgery for nonunion in patients treated with intramedullary nailing for midshaft fractures of the tibia. Retrospective cohort analysis. Data were sourced from the PearlDiver national database. Patients were identified through the PearlDiver database by using Current Procedural Terminology and International Classification of Diseases (ICD-10) codes. Included patients had undergone intramedullary nailing for midshaft fractures of the tibia between 2015 and 2020 and subsequently underwent revision surgery due to nonunion. The primary outcome measured in this study was the rate of nonunion following intramedullary nailing for the different types of tibial shaft fractures (closed, Type I/II open, Type III open). For each fracture subtype, the study compared nonunion rates between those who received enoxaparin in the postoperative period and those who did not receive enoxaparin at any time during the first 6 weeks postoperatively. Factors such as the timing and duration of enoxaparin therapy and demographic variables were also considered. The study included 16,986 patients, average age was 49.2 years (SD 17.3); 43.1% were female. Five hundred four patients required revision surgery for nonunion (3.4%). Among patients who did not receive enoxaparin, the nonunion rates were 1.6%, 3.9%, and 6.9% for closed, Type I/II open, and Type III open fractures, respectively. For patients who received enoxaparin within the first 2 weeks, the nonunion rates were 2.6%, 4.7%, and 7.9% for closed (RR = 1.67, P < 0.0001), Type I/II open (RR = 1.21, P < 0.0001), and Type III open (RR = 1.17, P = 0.355) fractures, respectively. Logistic regression confirmed enoxaparin was independently associated with nonunion (odds ratios [OR] = 1.75, P = 0.0013 for closed fractures; OR = 1.51, P = 0.034 for Type I/II open fractures). Tobacco use was also a contributing factor (OR = 2.43, P < 0.0001 for closed fractures; OR = 2.00, P < 0.0001 for Type I/II open fractures; OR = 2.04, P = 0.0008 for Type III open fractures). The postoperative use of enoxaparin was associated with an elevated risk of nonunion in patients treated with intramedullary nailing for fractures of the tibial shaft. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients with fibromyalgia have increased risk of 90-day postoperative adverse events following arthroscopic rotator cuff repair

BackgroundArthroscopic rotator cuff repair (RCR) is a common surgical intervention for symptomatic rotator cuff tears when conservative management fails. Understanding the potential correlation of short- and longer-term outcomes associated with defined comorbidities can help with patient selection, counseling, and related care pathways. The association of fibromyalgia, one potential comorbidity, with outcomes following RCR has not been reported in the literature. MethodsPatients with and without fibromyalgia diagnosed prior to undergoing RCR were identified from the PearlDiver Mariner161 database between 2016 and April 30, 2022, using Current Procedural Terminology (CPT) codes. Exclusion criteria were age less than 18 years, a diagnosis of neoplasm, trauma, or infection within 90 days prior to surgery, and postoperative records of fewer than 90 days. Patients with and without fibromyalgia were matched 1:4 based on age, sex, and Elixhauser Comorbidity Index (ECI).Ninety-day adverse events were assessed. Severe adverse events were defined as the occurrence of sepsis, surgical site infection, cardiac events, deep vein thrombosis, or pulmonary embolism. Minor adverse events were defined as the occurrence of wound dehiscence, urinary tract infection, pneumonia, transfusion, hematoma, or acute kidney injury. Also identified was the occurrence of any adverse event, emergency department (ED) visits, and readmission. These outcomes were compared with multivariate analysis. One-year revisions were assessed with Kaplan-Meier curves and compared with the log-rank test. ResultsIn total, 295,169 RCR patients were identified, of which fibromyalgia was noted for 12,366 (4.2%). Following matching, the final cohort sizes for those with and without fibromyalgia were 11,387 and 45,354 respectively.Diagnosis of fibromyalgia was independently associated with increased risk of all individual adverse events as well as aggregated incidence of severe, minor, and any adverse events (p<0.0001 for all). Additionally, patients with fibromyalgia had independently 90-day increased odds of ED utilization (p<0.0001). There was no statistically significant difference in reoperation between the cohorts within 1 year of surgery. Discussion and ConclusionFibromyalgia was associated with significantly increased 90-day postoperative adverse events and ED visits. These findings are relevant in surgical planning but are also balanced by a lack of difference in one-year revisions.

Racial Disparities in Microinvasive Glaucoma Surgery for Management of Primary Open-Angle Glaucoma: A Propensity Matched Cohort Study: Racial Disparities in MIGS for the Management of POAG

PurposeTo evaluate racial/ethnic differences in the use of microinvasive glaucoma surgery (MIGS) for the management of mild-moderate primary open-angle glaucoma (POAG) in the United States. DesignRetrospective cohort study. ParticipantsPatients with a diagnosis of mild or moderate POAG, as defined by current procedural terminology (CPT) codes, were included. The experimental group comprised African American (AA) patients and the control group consisted of patients without an AA designation in the TriNetX database. MethodsPropensity scoring was used to match cohorts for age at diagnosis, Charlson Comorbidity Index, sex, nicotine dependence, glaucoma medications, family history of POAG, Body Mass Index, and weight. Outcome was incidence of MIGS over 1 year of follow up. Odds ratios were calculated between cohorts Main Outcome MeasureIncidence of MIGS over 1 year of follow-up post-POAG diagnosis. Results63,418 POAG patients were included (50% AA, 50% non-AA). AA patients were found to undergo MIGS at a significantly lower rate (1,268 of 31,709) compared to non-AA patients (1,508 of 31,709) (OR 0.834, 95% CI: 0.773 – 0.900). ConclusionAlthough POAG is understood to be more prevalent among African Americans, these patients display lower utilization of MIGS, suggesting a possible nationwide racial disparity in the management of POAG.

Serotonergic Antidepressants are Associated With Higher Rates of Hematoma After Anterior Cervical Spine Surgery: A Large Propensity-matched Cohort Analysis.

Large database propensity-matched retrospective cohort analysis. This study aimed to investigate the potential effects of serotonergic antidepressants on outcomes after anterior cervical spine surgery (ACSS). It was hypothesized that the perioperative use of serotonergic antidepressants would be associated with higher rates of hematoma formation and worse outcomes after ACSS. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been associated with worse outcomes after orthopaedic procedures. A retrospective cohort analysis was performed using TriNetX, an aggregated and de-identified electronic health record platform. Patients who underwent anterior cervical surgery were included via Current Procedural Terminology (CPT) codes and the International Classification of Disease (ICD-10) encounter diagnosis codes. Cohorts were 1:1 propensity matched across seven demographic and medical comorbidity parameters, and outcomes were compared. The incidence of adverse outcomes, as well as healthcare utilization, within 14 days, 30 days, 90 days and 2-years post-operatively was evaluated. Following propensity matching, each cohort consisted of 9,249 patients, for a total of 18,498 patients included in final statistical analysis. SSRI/SNRI's were associated with higher odds of hematoma formation within 7-days (0.69% vs. 0.46%, OR 1.5 [95% CI 1.02-2.2], P=0.04) and within 14-days postoperatively (0.81% vs. 0.52%, OR 1.6 [95% CI 1.1-2.3], P=0.01. Within 30- and 90-days, SSRI/SNRI's were associated with higher risk of emergency department utilization (30-day OR 1.30 [1.1-1.4]; 90-day OR 1.3 [1.2-1.4]) and irrigation & debridement (I&D) (30-day OR 1.9 [1.2-3.0]). SSRIs/SNRIs were also associated with significantly higher risk of I&D within 2-years (OR 1.3 [1.1-1.6]). The use of serotonergic antidepressants perioperatively was associated with higher odds and risk of numerous outcomes, including hematoma formation, emergency department utilization and the need for irrigation & debridement. Future prospective studies are required to confirm these results. III; retrospective cohort analysis.

Revision A1 Pulley Release: An Analysis of Risk Factors Using a National Database

Trigger finger release (TFR) is a commonly performed procedure in hand surgery. Trigger finger release has a high success rate, but recurrence can occur. Data on revision TFR (rTFR) are sparse, with little known regarding factors associated with the need for revision surgery. Our purpose was to analyze risk factors associated with rTFR procedures. Using a national database (PearlDiver Research Program), patients who underwent TFR between 2015 and 2022 were identified using Current Procedural Terminology and International Classification of Diseases (ICD)-10 codes. Patients were included if they received an ICD-10 diagnosis of trigger finger on the same day as their release or within 2 weeks of their procedure. Patients who underwent rTFR were determined through identification of a secondary procedure completed in the same digit on the ipsilateral hand performed after the index procedure. Revision rates at 1, 3, and 5 years were recorded. Demographics and comorbidities were categorically examined via univariate and multivariable logistic regression analyses. A total of 46,613 patients meeting inclusion criteria were identified after TFR with 1,793 (3.85%) undergoing revision release. Multivariable analysis demonstrated that diabetes, ischemic heart disease, and male sex were associated with statistically significantly increased odds of revision procedures at 1, 3, and 5 years from the initial operation. Age >65 years and hypertension were associated with an increased odds of revision surgery at 3 and 5 years, and carpal tunnel syndrome as a risk factor at 1 and 3 years only. Hypothyroidism was associated with a decreased revision rate at all time points and tobacco use at 5 years only. These data demonstrate that male sex, diabetes, and heart disease are risk factors for requiring revision TFR in the short and medium terms. This information can add to preoperative counseling with patients undergoing surgical treatment of trigger digits. Prognostic II.

Acquired buried penis: an observational study characterizing the variability in procedural codes reported during surgery.

Adult acquired buried penis (ABP) is a heterogenous condition and surgical treatment typically includes several steps. Additionally, there is no consensus on which current procedural terminology (CPT) codes to utilize for these steps. Our objective is to characterize the variability in CPT codes reported for ABP surgeries. We hypothesize that the heterogeneous disease process combined with a lack of consensus on appropriate CPT codes will result in marked variability in CPT codes reported during surgery for ABP. Data was collected from American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2007-2020. We included adults undergoing surgery for ABP. All CPT codes were grouped into different anatomic categories: penile procedures, scrotal procedures, pannus-related procedures, urethral procedures, tissue transfers, and skin grafts. Codes not fitting these categories were labeled "Other". Our study included 146 patients. There were 413 total CPT codes reported with 82 unique codes in our cohort. The average number of codes per patient was 2.8, with a range from 1 to 9. There were many unique codes in each anatomic category: 18 different codes within penile procedures, 7 within pannus procedures, 8 within skin grafting, 4 within scrotal procedures, 7 within tissue transfers, and 19 within urethral. There was marked variability in individual code use with each code being reported anywhere from 1 to 58 times. Urologists were the primary surgeons in 69% (n=101). We found marked variability in CPT codes reported during surgery for ABP. This suggests the need for our stakeholder organizations to support efforts that would allow consensus on which codes should be utilized for this increasingly recognized condition.