Translating coding lists in administrative claims-based research for cardiovascular procedures.

BACKGROUND: To effectively use administrative claims for healthcare research, clinical events must be inferred from coding data according to validated algorithms. In October 2015, the United States transitioned from the International Classification of Diseases Ninth Revision (ICD-9) to the Tenth Revision (ICD-10). We describe our method to derive new ICD-10 codes for outcomes after vascular procedures from our prior, validated ICD-9 codes. METHODS: We began with validated ICD-9 coding lists known to represent outcomes after lower extremity revascularization, thoracic aortic endograft placement, abdominal aortic aneurysm reintervention, and carotid revascularization. We used the publicly available general equivalence mapping tools to derive corresponding ICD-10 codes for each of the ICD-9 codes in our current lists. The resulting lists were then manually reviewed by multiple authors to ensure clinical relevance for appropriate event detection. Clinically nonrelevant and duplicated codes were removed. RESULTS: A total of 475 ICD-9 codes were translated to ICD-10 with a 98-fold increase (n = 46,630) in the total number of codes. Overall, we found that 77% of codes (n = 35,833) were either duplicated or not clinically relevant upon manual review. For example, for thoracic aortic endograft placement, 97 ICD-9 codes mapped to 14,661 ICD-10 codes in total. A total of 890 codes were removed as duplicates and 9035 codes were removed during manual clinical review. The resultant, reviewed list contained 4736 ICD-10 codes representing a 49-fold increase from the initial ICD-9 list. Findings were similar across the other procedures studied. CONCLUSIONS: ICD-10 has expanded the number of codes necessary to describe outcomes after vascular procedures. More than 75% of the codes obtained using the general equivalence mapping database were either duplicated or not clinically relevant. Manual review of codes by researchers with clinical knowledge of the procedures is imperative.

Modern radiosurgical and endovascular classification schemes for brain arteriovenous malformations.

Stereotactic radiosurgery (SRS) and endovascular techniques are commonly used for treating brain arteriovenous malformations (bAVMs). They are usually used as ancillary techniques to microsurgery but may also be used as solitary treatment options. Careful patient selection requires a clear estimate of the treatment efficacy and complication rates for the individual patient. As such, classification schemes are an essential part of patient selection paradigm for each treatment modality. While the Spetzler-Martin grading system and its subsequent modifications are commonly used for microsurgical outcome prediction for bAVMs, the same system(s) may not be easily applicable to SRS and endovascular therapy. Several radiosurgical- and endovascular-based grading scales have been proposed for bAVMs. However, a comprehensive review of these systems including a discussion on their relative advantages and disadvantages is missing. This paper is dedicated to modern classification schemes designed for SRS and endovascular techniques.

Standards of reporting in open and endovascular aortic surgery (STORAGE guidelines).

The number of patients undergoing surgery on the thoracic and thoraco-abdominal aorta has been steadily increasing over the past decade. This document aims to give guidance to authors reporting on results in aortic surgery by clarifying definitions of aortic pathologies, open and endovascular techniques and by listing clinical parameters that should be provided for full presentation of patients' clinical profile and in particular, their outcome. The aim is to help find a common language in the treatment of aortic disease and to contribute to a better understanding of this patient population.

Claims Variability in Charges and Payments for Common Open and Endovascular Procedures.

BACKGROUND: Cost-effectiveness in healthcare is being increasingly scrutinized. Data regarding claims variability for vascular operations are lacking. Herein, we aim to describe variability in charges and payments for aortoiliac (AI) and infrainguinal (II) revascularizations. METHODS: We analyzed 2012-2014 claims data from a statewide claims database for procedures grouped by Current Procedural Terminology codes into II-open (II-O), II-endovascular (II-E), AI-open (AI-O), and AI-endovascular interventions (AI-E). We compared charges and payments in urban (≥50,000 people, UAs) versus rural areas (<50,000 people, RAs). Amounts are reported in $US as median with interquartile range. Cost-to-charge ratios (CCRs) as a measure of reimbursement were calculated as the percentage of the charges covered by the payments. Wilcoxon rank-sum tests were performed to determine significant differences. RESULTS: A total of 5,239 persons had complete claims data. There were 7,239 UA and 6,891 RA claims, and 1,057 AI claims (AI-E = 879, AI-O = 178) and 4,182 II claims (II-E = 3,012, II-0 = 1,170). Median charges were $5,357 for AI [$1,846-$27,107] and $2,955 for II [$1,484-$9,338.5] (P < 0.0001). Median plan payment was $454 for AI [$0-$1,380] and $454 for II [$54-$1,060] (P = 0.67). For AI and II, charges were significantly higher for UA than RA (AI: UA $9,875 [$2,489-$34,427], RA $3,732 [$1,450-$20,595], P < 0.0001; II: UA $3,596 [$1,700-$21,664], RA $2,534 [$1,298-$6,169], P < 0.0001). AI-E charges were higher than AI-O (AI-E $7,960 [$1,699-$32,507], AI-O $4,774 [$2,636-$7,147], P < 0.0001), but AI-O payments were higher (AI-E $424 [$0-$1,270], AI-O $869 [$164-$1,435], P = 0.0067). II-E charges were higher (II-E $2,994 [$1,552-$22,164], II-O $2,873 [$1,108-$5,345], P < 0.0001), but II-O payments were higher (II-E $427 [$50-$907], II-O $596 [$73-$1,299], P < 0.0001). CCRs were highest for II operations and UAs. CONCLUSIONS: Wide variability in claim charges and payments exists for vascular operations. AI procedures had higher charges than II, without any difference in payments. UA charged more than RA for both AI and II operations, but RA had higher payments and CCRs. Endovascular procedures had higher charges, while open procedures had higher payments. Charge differences may be related to endovascular device costs, and further research is necessary to determine the reasons behind consistent claims variability between UA and RA.

Financial implications of coding inaccuracies in patients undergoing elective endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Previous cost analyses have found small to negative margins between hospitalization cost and reimbursement for endovascular aneurysm repair (EVAR). Hospitals obtain reimbursement on the basis of Medicare Severity Diagnosis Related Group (MS-DRG) coding to distinguish patient encounters with or without major comorbidity or complication (MCC). This study's objective was to evaluate coding accuracy and its effect on hospital cost for patients undergoing EVAR. METHODS: A retrospective, single university hospital review of all elective, infrarenal EVARs performed from 2010 to 2015 was completed. Index procedure hospitalizations were reviewed for MS-DRG classification, comorbidities, complications, length of stay (LOS), and hospitalization cost. Patients' comorbidities and postoperative complications were tabulated to verify accuracy of MS-DRG classification. Misclassified patients were audited and reclassified as "standard" or "complex" on the basis of a corrected MS-DRG: standard for 238 (major cardiovascular procedure without MCC) and complex for 237 (major cardiovascular procedure with MCC). RESULTS: There were 104 EVARs identified, including 91 standard (original MS-DRG 238, n = 85; MS-DRG 254, n = 6) and 13 complex hospitalizations (original MS-DRG 237, n = 9; MS-DRG 238, n = 3; MS-DRG 253, n = 1). On review, 3% (n = 3) of the originally assigned MS-DRG 238 patients were undercoded while actually meeting MCC criteria for a 237 designation. Hospitalizations coded with MS-DRG 253 and 254 were considered billing errors because MS-DRG 237 and 238 are more appropriate and specific classifications as major cardiovascular procedures. Overall, there was a 9.6% miscoding rate (n = 10), representing a total lost billing opportunity of $587,799. Mean LOS for standard and complex hospitalizations was 3.0 ± 1.5 days vs 7.8 ± 6.0 days (P < .001), with respective intensive care unit LOS of 0.4 ± 0.7 day vs 2.6 ± 3.1 days (P < .001). Postoperative complications occurred in 23% of patients; however, not all met the Centers for Medicare and Medicaid Services criteria as MCC. Miscoded complexity was found to be due to postoperative events in all patients rather than to missed comorbidities. Mean hospitalization cost for standard and complex patients was $28,833 ± $5597 vs $41,543 ± $12,943 (P < .001). Based on institutional reimbursement data, this translates to a mean loss of $5407 per correctly coded patient. Miscoded patients represent an additional overall reimbursement loss of $140,102. CONCLUSIONS: Our study reveals a large lost billing opportunity with miscoding of elective EVARs from 2010 to 2015, with errors in categorization of the procedure as well as miscoding of complexity. The revenue impact is potentially significant in this population, and additional reviews of coding practices should be considered.

Performance of current claims-based approaches to identify aortic dissection hospitalizations.

OBJECTIVE: To describe index visits for acute aortic dissection (AD) to an academic center and validate the prevailing claims-based methodology to identify and stratify them. METHODS: Inpatient hospitalizations at a single center assigned an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis code for AD from January 2005 to September 2015 were identified. Diagnoses were verified by review of medical records and imaging studies. All visits were secondarily stratified with the algorithm based on ICD-9 codes. Sensitivity and specificity analyses were conducted to evaluate the ability of the algorithm to correctly identify acute AD by Stanford class and treatment modality (type A open repair [TAOR], type B open repair [TBOR], thoracic endovascular repair [TEVAR], medical management [MM]). RESULTS: In the study interval, there were 1245 visits coded for AD attributed to 968 unique patients. Chart review verification demonstrated that the majority of visits were for AD (79%; n = 981), of which 32% (n = 310) were for an index acute AD event. The true distribution of acute AD visit classifications was TAOR (46.1%; n = 143), TBOR (5.2%; n = 16), TEVAR (7.7%; n = 24), and MM (39.4%; n = 122). The algorithm, which used ICD-9 codes, identified 631 acute visits and stratified them as TAOR (27.1%; n = 171), TBOR (4.1%; n = 26), TEVAR (4.9%; n = 31), and MM (63.9%; n = 403). Analyses demonstrated high specificities, but generally low sensitivities of the algorithm (TAOR: sensitivity, 58%, specificity, 92%; TBOR: sensitivity, 13%, specificity, 98%; TEVAR: sensitivity, 17%, specificity, 98%; MM: sensitivity, 73%, specificity, 72%). CONCLUSIONS: The prevalent claims-based strategy to identify hospitalizations with acute AD is specific, but lacks sensitivity. Caution should be exercised when studying AD with ICD-9 codes and improvements to existing claims-based methodologies are necessary to support future study of acute AD.

Surgeon leadership in the coding, billing, and contractual negotiations for fenestrated endovascular aortic aneurysm repair increases medical center contribution margin and physician reimbursement.

BACKGROUND: Fenestrated endovascular aneurysm repair (FEVAR) allows endovascular treatment of thoracoabdominal and juxtarenal aneurysms previously outside the indications of use for standard devices. However, because of considerable device costs and increased procedure time, FEVAR is thought to result in financial losses for medical centers and physicians. We hypothesized that surgeon leadership in the coding, billing, and contractual negotiations for FEVAR procedures will increase medical center contribution margin (CM) and physician reimbursement. METHODS: At the UMass Memorial Center for Complex Aortic Disease, a vascular surgeon with experience in medical finances is supported to manage the billing and coding of FEVAR procedures for medical center and physician reimbursement. A comprehensive financial analysis was performed for all FEVAR procedures (2011-2015), independent of insurance status, patient presentation, or type of device used. Medical center CM (actual reimbursement minus direct costs) was determined for each index FEVAR procedure and for all related subsequent procedures, inpatient or outpatient, 3 months before and 1 year subsequent to the index FEVAR procedure. Medical center CM for outpatient clinic visits, radiology examinations, vascular laboratory studies, and cardiology and pulmonary evaluations related to FEVAR were also determined. Surgeon reimbursement for index FEVAR procedure, related adjunct procedures, and assistant surgeon reimbursement were also calculated. All financial analyses were performed and adjudicated by the UMass Department of Finance. RESULTS: The index hospitalization for 63 FEVAR procedures incurred $2,776,726 of direct costs and generated $3,027,887 in reimbursement, resulting in a positive CM of $251,160. Subsequent related hospital procedures (n = 26) generated a CM of $144,473. Outpatient clinic visits, radiologic examinations, and vascular laboratory studies generated an additional CM of $96,888. Direct cost analysis revealed that grafts accounted for the largest proportion of costs (55%), followed by supplies (12%), bed (12%), and operating room (10%). Total medical center CM for all FEVAR services was $492,521. Average surgeon reimbursements per FEVAR from 2011 to 2015 increased from $1601 to $2480 while the surgeon payment denial rate declined from 50% to 0%. Surgeon-led negotiations with the Centers for Medicare & Medicaid Services during 2015 resulted in a 27% increase in physician reimbursement for the remainder of 2015 ($2480 vs $3068/case) and a 91% increase in reimbursement from 2011 ($1601 vs $3068). Assistant surgeon reimbursement also increased ($266 vs $764). Concomitant FEVAR-related procedures generated an additional $27,347 in surgeon reimbursement. CONCLUSIONS: Physician leadership in the coding, billing, and contractual negotiations for FEVAR results in a positive medical center CM and increased physician reimbursement.

Tratamiento endovascular de aneurisma de aorta abdominal en paciente trasplantado renal con oclusión de ilíaca externa ipsilateral al injerto / Endovascular abdominal aortic aneurysm repair in a renal transplant patient with external iliac occlusion ipsilateral to the graft

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Tratamiento endovascular de la enfermedad aneurismática renal / Endovascular treatment of renal aneurysm disease

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A multidisciplinary approach to vascular surgery procedure coding improves coding accuracy, work relative value unit assignment, and reimbursement.

BACKGROUND: Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement. METHODS: This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy. RESULTS: During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding. CONCLUSIONS: Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

¿Existe algún factor de riesgo predictivo de mortalidad a corto plazo en pacientes de alto riesgo intervenidos de aneurismas de aorta abdominal mediante endoprótesis? / Is there any predictive risk factor of short-term mortality in high risk patients operated on for aortic abdominal aneurysms using endoprosthesis?

OBJETIVOS: Identificar factores predictivos de mortalidad a corto plazo (<24 meses) en pacientes con aneurisma de aorta abdominal (AAA), de alto riesgo quirúrgico, tratados mediante endoprótesis. MATERIAL Y MÉTODOS: Estudio retrospectivo mediante revisión de historias clínicas entre enero de 2006 y junio de 2010. El seguimiento medio de los pacientes fue de 23,7 meses (DE = 16,3; rango: 0-62). Se compara el grupo de mortalidad a corto plazo (<24 meses) con el resto, mediante regresión logística multivariante. RESULTADOS: El 3,5% (2 casos) falleció durante el ingreso y el 30,9% (17 casos) durante el periodo de seguimiento. La media de supervivencia fue 41,1 meses (34-48,2; mediana = 40 meses). La mortalidad antes de 24 meses fue el 21% (12 pacientes). En el análisis multivariante se encontró que el único factor predictivo de mortalidad a corto plazo fue la presencia de enfermedad pulmonar obstructiva crónica (EPOC) (p = 0,014; OR 13,7; IC = 1,7-109). CONCLUSIONES: La EPOC en pacientes de alto riesgo quirúrgico parece ser indicativa de mortalidad a corto plazo

OBJECTIVES: To detect any risk factor of short-term mortality in high risk patients undergoing endovascular abdominal aortic aneurism (EVAR) repair. MATERIAL AND METHODS: A retrospective study was conducted from January 2006 to June 2010, with a mean follow-up of 23.7 months. A multiple logistic regression model was used to evaluate variables of mortality after EVAR in early mortality patients. RESULTS: Two (3.5%) cases died during hospital admission, and 30.9% during the follow-up period. Short-term mortality rate (before 24 months) was 21% (12 patients). chronic obstructive pulmonary disease (COPD) was the only significant predictor of short-term mortality (P=.014; OR 13.7; 95% CI = 1.7-109). CONCLUSIONS: COPD in high risk patients could predict short-term mortality after EVAR

Disección de aorta tipo B no complicada: ¿debe ser todavía el tratamiento médico la mejor opción? Sí, el tratamiento conservador es la mejor opción / Uncomplicated type B aortic dissection: Must medical treatment still be the best option? Yes, conservative treatment is the best option

La disección aguda tipo B es una de las más temibles enfermedades que pueden acontecer en la aorta. Clásicamente, el tratamiento recomendado ha sido conservador, encaminado sobre todo a un correcto control de la tensión arterial y el dolor. Sin embargo, el advenimiento de la terapia endovascular y su aplicación satisfactoria en disecciones aórticas complicadas (pacientes con inestabilidad hemodinámica, isquemia periférica, malperfusión visceral o rotura contenida) ha expandido su empleo en todos los casos. Este hecho ha suscitado una importante controversia en relación con el tratamiento adecuado de esta dolencia, especialmente en aquellas disecciones no complicadas. Hasta el momento actual, el tratamiento endovascular parece que se asocia a un mayor grado de trombosis de la luz falsa y una remodelación más favorable de la aorta durante su seguimiento, pero faltan datos que demuestren que esa actitud mejora la supervivencia global de los pacientes. Los autores de estos artículos analizan la eficacia de la terapia endovascular en disecciones no complicadas de la aorta descendente, revisando las últimas evidencias a favor y en contra de su empleo

Acute type-B dissection is one of the most dreaded diseases that can occur in the aorta. Classically, the preferred medical treatment has been the perfect control of the blood pressure and the pain. However, the advent of endovascular therapy and its successful implementation in complicated aortic dissections (patients with hemodynamic instability, peripheral ischemia, visceral malperfusion or contained rupture) has expanded its use in all cases. This has led to considerable controversy regarding the appropriate treatment of this disease, especially in uncomplicated aortic dissections. To date, endovascular therapy appears to cause more thrombosis of the false lumen and a more favorable remodeling of the aorta during the followup, but missing data shows that this approach improves the overall survival of these patients. The authors of these articles analyze the effectiveness of endovascular therapy in uncomplicated dissections of the descending aorta, reviewing the latest evidence for and against its use

Tratamiento endovascular del divertículo de Kommerell / Endovascular treatment of Kommerell's diverticulum

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Nikolay L. Volodos. Un pionero del EVAR / Nikolay L. Volodos. A pioneer of EVAR

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¿Es la carga de trombo y su localización en el saco un factor protector de endofugas tipo II? / Is thrombus load and location a protection factor of type II endoleaks?

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