Diagnosis and procedure coding for bone mass measurement.

OBJECTIVE: To provide background information and practical advice about coding for submission of claims for reimbursement for performing bone mass measurement studies. METHODS: The current procedural terminology (CPT) codes for diagnoses and procedures related to reduced bone mass and osteoporosis are reviewed, and Medicare and other payer policies are discussed. RESULTS: Although considerable differences exist in payer policies relative to bone mass measurement, notable consistency is developing for Medicare patients. The CPT codes for pertinent outpatient and inpatient services, and applicable CPT modifiers, are outlined. In addition, examples are provided of criteria imposed for qualification for coverage. If a carrier or payer is not expected to provide coverage for the performance of a bone mass measurement study, an advance beneficiary notice (waiver statement) should be processed and the patient should be informed about the potential responsibility for payment before the test is done. CONCLUSION: Osteoporosis is an important and costly disorder that is rapidly increasing in prevalence in our society. Clinical endocrinologists have a critical role in the management of patients with this condition and an opportunity to contribute to high-quality care. Proper selection of patients for assessment and treatment and an understanding of certain restrictions and necessary documentation for insurance coverage may help obtain reimbursement for their care.

Lifestyle modifications in the prevention and treatment of hypertension.

OBJECTIVE: To present an objective, evidence-based review of the current literature on the role of lifestyle factors in hypertension. METHODS: We discuss the reported roles of obesity and overweight, nutritional factors, alcohol, physical activity, and smoking in the prevention and treatment of hypertension. RESULTS: For all age-groups and in both sexes, cross-sectional and prospective studies have shown a direct strong relationship between weight and blood pressure. In general, overweight is associated with a twofold to sixfold increase in the risk of developing hypertension. Clinical trials have proved that weight loss is effective in the primary prevention of hypertension as well as in the reduction of both systolic and diastolic blood pressure in patients with normal or high blood pressure. A decreased intake of dietary sodium has been demonstrated to have a hypotensive effect, both alone and as an adjunctive measure to pharmacologic therapy. Although no consensus currently exists about the role of potassium intake in prevention or control of hypertension, some studies support the protective value of high intake of potassium. A consistent relationship has been noted between consumption of alcohol and increased blood pressure, and reduced intake of alcohol has been shown to decrease blood pressure significantly. An inverse relationship exists between blood pressure and physical activity, independent of overweight or obesity. Moreover, increased physical activity helps lower both systolic and diastolic blood pressure. In a study of the effect of smoking and use of smokeless tobacco in healthy middle-aged men, ambulatory diastolic blood pressures were increased in both smokers and smokeless tobacco users in comparison with nonusers. CONCLUSION: Ample evidence supports the beneficial effects of healthful lifestyle modifications in the prevention and management of hypertension. Therefore, physicians should be motivated to provide guidance to the population relative to lifestyle practices that can help prevent and control hypertension.

Practical application of recombinant thyrotropin testing in clinical practice.

OBJECTIVE: To review the indications for use of recombinant thyrotropin (rTSH) and outline the details of implementation of rTSH diagnostic testing in patients with treated thyroid cancer. METHODS: We discuss the results of published clinical trials that have compared rTSH-stimulated testing with conventional withdrawal of thyroid hormone suppressive therapy. Appropriate candidates for rTSH testing are described, and the typical schedule for rTSH testing and follow-up is presented. An overview of coding and documentation for reimbursement is also provided. RESULTS: Clinical studies have found no significant difference in the combined sensitivity of (131)I scans and serum thyroglobulin measurements for detection of recurrent thyroid cancer after rTSH stimulation versus withdrawal of thyroid hormone therapy. As expected, patients have fewer symptoms and a more favorable mood state after use of rTSH. Patients with thyroid cancer who have undergone total or near-total thyroidectomy followed by 131I ablation can be considered for rTSH testing. For low-risk patients, two cycles of rTSH testing 1 to 2 years apart, followed by testing every 3 to 5 years, are recommended. For moderate- to high-risk patients who have undergone one cycle of negative levothyroxine-withdrawal testing, two cycles of rTSH testing at a 6- to 12-month interval, followed by testing every 1 to 3 years for at least the first decade of follow-up, are recommended. Most commercial insurance, Medicare, and Medicaid carriers now cover rTSH, either in a prescription drug plan or under major medical benefits. CONCLUSION: Radioiodine scanning and serum thyroglobulin measurement after intramuscular injection of rTSH are valuable new monitoring options in patients with treated thyroid cancer, avoiding the adverse effects of hypothyroidism.

An Association Between Varying Degrees of Hypothyroidism and Hypercholesterolemia in Women: The Thyroid-Cholesterol Connection.

Evidence of an association between subclinical hypothyroidism and cardiovascular disease is mounting. The impact of thyroid hormone on lipid levels is primarily mediated through triiodothyronine (T(3))-bound thyroid protein binding and activation of the promoter regions of the low-density lipoprotein receptor and 3-hydroxy-3-methylglutaryl coenzyme A-reductase genes, leading to a reduction in serum cholesterol levels. Thus, the decreased T(3) seen in hypothyroidism may result in increased serum cholesterol. Although a clear correlation exists between overt hypothyroidism and clinically significant hypercholesterolemia, there is a logarithmic relationship between thyroid-stimulating hormone and cholesterol, and the effects of subclinical hypothyroidism on cardiovascular disease are under debate. However, current data suggest that normalizing even modest thyroid-stimulating hormone elevations may result in improvement in the lipid profile. (c)2001 CHF, Inc.

Socioeconomics of coding for endocrine services.

OBJECTIVE: To review the current coding systems for procedures and services as well as for diagnoses and to address special issues in endocrine disorders such as diabetes relative to reimbursement. METHODS: A method of coding for services to maximize reimbursement and minimize errors and denials of claims is discussed. Useful checklists and resources are also provided. RESULTS: Medicare policies have become increasingly complex, and continual changes in coverage of medical services and procedures can be confusing. Suggestions are presented for securing timely payment for claims, and thorough documentation is emphasized. "Bundling" of codes by payers, a common practice with new screening software systems, is explained. Strategies are described for negotiating contracts that specify prompt payment periods and include penalties for late payments. CONCLUSION: Awareness of current codes for health care services and diagnoses will facilitate the processing of claims and optimize reimbursements.

Diabetes education programs and the endocrinologist.

In the past, control of diabetes was considered important, but studies had not substantiated the effect of high-quality care on the outcome for patients with diabetes. Recently, however, published results of the Diabetes Control and Complications Trial indicated that optimal control of diabetes minimized the associated complications. As a consequence, educational efforts have focused on informing and encouraging patients with diabetes to help achieve and maintain the best possible medical care. This situation has created a market for products and services to assist patients with diabetes, and many nonphysicians have promoted their products without actual participation in a team effort to improve outcomes for patients with diabetes. Clinical endocrinologists, who are experts in the management of diabetes, should assume a leadership role on the diabetes-care team and should not relinquish this responsibility to those who are less qualified to provide care for the growing number of patients with diabetes who seek optimally effective treatment.

Practical tips on coding for diabetes care.

This article is designed to assist with the challenging effort to obtain reimbursement for health-care services to patients with diabetes. The basics of coding diagnoses and services are presented, including background information and specific examples of the use of codes that are particularly pertinent to the clinical endocrinologist's care of the patient with diabetes. The coding of diagnoses with use of the current International Classification of Diseases, 9th revision, clinical modification (ICD-9-CM) classification system and the coding of outpatient and inpatient services by using current procedural terminology (CPT) codes and modifiers are outlined, including the use of the relatively new prolonged physician services codes. A discussion of reimbursement for diabetes education and pertinent revenue codes for hospital services is included, and resource references for further study are provided.

Lessons from managed care.

The infiltration of the health-care environment by health maintenance organizations has been promoted, in part, by instilling fear in physicians about their patient base and creating an illusion of free choice for patients. Within capitation arrangements, specialists are often underpaid for management of complex cases and uncompensated for investment of long hours in ancillary activities. Clinical endocrinologists have been expected to develop algorithms for conditions such as diabetic ketoacidosis, yet application of such guidelines by other clinicians may yield suboptimal results. The transformation of medicine to a business and the focus of insurance administrators on profit rather than high-quality care currently tend to eliminate specialists. Studies that show that high-quality specialty care improves outcomes clinically (and therefore financially) should curb this trend. Nevertheless, a new paradigm for medical care is evolving. Because capitation will not be the only model, clinical endocrinologists should not allow themselves to be exploited in such an arrangement.

Coding for endocrine services: using the new codes and the evocative/suppression testing protocols.

In 1994, a series of new current procedural terminology (CPT) codes for the description of services provided primarily by clinical endocrinologists were approved. Included were codes for 22 new endocrine evocative/suppression testing panels that represent the laboratory analyte portions of a series of endocrine protocols. These new codes were to be used in conjunction with another series of new codes for the physician's services, called prolonged physician services. These two new series of CPT codes are discussed in this article, and useful examples of their application, not described elsewhere to date, are provided.

Coding: the history of the recognition of endocrinology services.

Until recent years, endocrinology services were reimbursed with the use of generic codes. Efforts to establish codes specifically for endocrinology tests, protocols, and services during the past 12 years are reviewed. The formation of the American Association of Clinical Endocrinologists and the involvement of their membership on behalf of clinical endocrinology are detailed. Presentation of three complex coding challenges exemplifies the need for ongoing efforts to improve and update endocrinology codes.

Quantitation of biliary excretion of drugs in man.

An experimental model was developed to allow extended investigation (up to3 days) of the kinetics of upper gastrointestinal elimination (including enterohepatic recirculation) of drugs or metabolites in normal subjects under near physiologic conditions. The test drug (100 mg carprofen) was given by mouth or through a triple-lumen nasogastric tube to the upper duodenum to three normal subjects. The amounts of drug and metabolite passing the gastrointestinal aspiration port for each time interval were calculated from the concentrations measured in the aspirate using dual nonabsorbable markers and continuous sampling and reinfusion of intestinal fluids. Crossover studies without intubation in the same subjects and comparisons to historical controls demonstrated that the intubation procedure did not affect normal kinetic data obtained from conventional blood and urine specimens. The model permits direct comparison of gastrointestinal-biliary clearance with renal and with total body clearance and is particularly useful in resolving kinetic questions of gastrointestinal-biliary excretion or recirculation of metabolites when a drug must be taken by mouth. Potential first-pass phenomena may also be investigated by means of incremental gastrointestinal clearance values.