Pediatric Limb Lengthening and Reconstruction Surgical Coding Survey Results.

BACKGROUND: In surgical specialties like orthopaedics, documenting the surgery performed involves applying the appropriate current procedural terminology (CPT) code(s). For limb reconstruction surgeons, the wide-ranging types of surgeries and rapid evolution of the field create a variety of factors making it difficult to code the procedures. We sought to (1) assess whether appropriate limb reconstruction codes currently exist and (2) determine whether there is agreement among experienced pediatric orthopaedic surgeons when applying these codes to similar cases. METHODS: A REDCAP survey comprised of 10 common pediatric limb reconstruction cases was sent to experienced pediatric limb reconstruction surgeons in the United States. Based on the description of each case, the surgeons were asked to code the cases as they usually would in their practice. There were no limitations regarding the number or the types of codes each surgeon could choose to apply to the case. Nine additional demographic and general coding questions were asked to gauge the responding surgeon's coding experience. RESULTS: Survey participants used various codes for each case, ranging from only 1 code to a maximum of 9 codes to describe a single case. The average number of codes per case ranged from 1.2 to 3.6, with an average of 2.5 among all 10 cases. The total number of unique codes provided by the respondents for each case ranged from 5 to 20. Only 3 of the 10 cases had an agreement >75% for any single code, and only 2 of the 10 cases had >50% agreement on any combination of 2 codes. CONCLUSIONS: There are dramatic variations in coding methods among pediatric orthopaedic limb reconstruction surgeons. This information highlights the need to improve the current CPT coding landscape. Possible solutions include developing new codes that better represent the work done, developing standardized guidelines with the existing codes to decrease variation, and improving CPT coding education by developing limb reconstruction coding "champions." LEVEL OF EVIDENCE: Level V.

A quality improvement initiative to reduce cast transitions in a pediatric hospital.

A quality improvement protocol was implemented in a large tertiary care pediatric hospital to reduce the rate of transitions from emergency department (ED)-applied casts to another form of immobilization (waterproof cast, removable brace, or sling). The local standard of care prior to implementing this quality improvement project involved applying long-arm casts in the ED for children presenting with stable upper extremity injuries (those not requiring a reduction). We created a multidisciplinary quality improvement team with orthopedic and ED providers, as well as cast technicians, with the aim of reducing the transition rate of ED-applied casts in clinic by 50%. Multiple Plan-Do-Study-Act cycles were performed and data were evaluated monthly. Charge fees were determined to assess differences in costs between splints and casts. An independent samples t-test for equality of means was used to determine the ED length of stay of each group. Baseline data determined a cast transition rate of 59.9%. After implementing the quality improvement protocol, the cast transition rate was reduced to 25.0%, a 58% reduction. The length of stay in the ED for a patient receiving a splint as opposed to a cast was 26.2 ± 8.0 min shorter. The charge to a patient receiving a splint rather than an ED-applied cast was $291.25 less. In conclusion, implementation of a multidisciplinary quality improvement protocol resulted in a more than 50% reduction in the transition rate of ED-applied casts in the clinic. Furthermore, healthcare charges to families were reduced by nearly $130 000 annually after implementation of this protocol.