Optimization of Current Procedural Terminology Coding in Complex Genitourinary Surgical Specimens.
Context.-- Complex surgical specimens are associated with complex Current Procedural Terminology (CPT) coding. Objective.-- To assess and optimize the accuracy of CPT coding of complex genitourinary specimens at our institution. Design.-- Baseline CPT codes for nephrectomy and cystectomy surgical pa...
| Publicado en: | Archives of Pathology & Laboratory Medicine Vol. 149; no. 9; pp. 846 - 852 |
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| Autores principales: | , , , , , , , , , , , , |
| Formato: | research tables/charts Journal Article |
| Publicado: |
College of American Pathologists
Sep2025
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=187816950&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 187816950 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 00039985 1FS jtl: Archives of Pathology & Laboratory Medicine issn: 00039985 maglogo: N pubinfo: dt: Sep2025 vid: 149 iid: 9 pid: 2550 pub: College of American Pathologists place: Northfield, Illinois artinfo: ui: 187816950 187816950 187816950 10.5858/arpa.2024-0118-OA 187816950 ppf: 846 ppct: 6 formats: fmt: @attributes: type: P tig: atl: Optimization of Current Procedural Terminology Coding in Complex Genitourinary Surgical Specimens. aug: au: Behrman, David B. Achram, Robert McClure, Carol Allen, Beverly E. Miller, Christine Shoffeitt, Carla J. Magliocca, Kelly R. Steward-Tharp, Scott M. Alexander, Cindy Triplet, Twanda Maloney, Catherine Ritenour, Chad W. M. Harik, Lara R. affil: Departments of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia sug: subj: Current Procedural Terminology Coding Specimen Handling Pathology, Clinical Cystectomy Nephrectomy Human Retrospective Design Record Review Descriptive Statistics Pearson's Correlation Coefficient Funding Source Georgia Reports ab: Context.-- Complex surgical specimens are associated with complex Current Procedural Terminology (CPT) coding. Objective.-- To assess and optimize the accuracy of CPT coding of complex genitourinary specimens at our institution. Design.-- Baseline CPT codes for nephrectomy and cystectomy surgical pathology specimens were examined during a 3-month period. Pathology reports were reviewed for accurate CPT coding, and commensurate tests of change were implemented. Post-test-of-change data were re-collected, analyzed, and compared to the baseline data. Results.-- Baseline data consisted of 71 genitourinary specimens (April to June 2021) and demonstrated undercoding in 46% (n = 33 of 71) of specimens, mostly in specimens with 2 or more billable organs. From findings in baseline data, we implemented test-of-change efforts consisting of awareness, education, and increased documentation and communication between all involved parties. Marked improvement was noted in the coding accuracy of specimens with 2 billable organs (pretest: n = 4 of 21, 19%; posttest: n = 14 of 21, 67%) and 3 or more billable organs (pretest: n = 0 of 16, 0%; posttest: n = 7 of 12, 58%) (P value = .002). Problematic areas included nephrectomy specimens resected with adrenal glands (pretest: n = 2 of 12, 17%; posttest: n = 12 of 14, 86%) and ureters for urothelial carcinoma (pretest: n = 0 of 10, 0%; posttest: n = 3 of 6, 50%), as well as regional lymph nodes commingled with resection specimens (pretest: n = 0 of 11, 0%; posttest: n = 7 of 9, 78%). Conclusions.-- A comprehensive approach involving all stakeholders is necessary for CPT coding of complex surgical specimens. Documentation and familiarity with coding rules, specifically bundling and unbundling, as well as clinical indications for resection, are important factors in optimizing CPT coding. pubtype: Academic Journal doctype: research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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