Surgical techniques for abdominal wall hernia repair have advanced, yet it is unclear if all patient populations experience these innovations equally. We hypothesized that in patients undergoing abdominal wall herniorrhaphy, there would be socioeconomic variation between robotic, laparoscopic, and open approaches. We performed a retrospective review of patients undergoing abdominal wall herniorrhaphy at a tertiary care center from 2013 through 2019. Patients were stratified by approach: laparoscopic (LH), open (OH), or robotic (RH). Insurance type was categorized as private, Medicare, or Medicaid/uninsured. Using zip code data, we obtained a Distressed Communities Index (DCI), which is comprised of 7 unique socioeconomic variables. We employed random forest (RF) modeling to predict surgical approach and determined each factor’s variable importance (VI) for our model. There were 559 patients; 39.7% (n = 222) LH, 33.3% (n = 186) OH, and 27% (n = 151) RH. The DCI (p < 0.01) and rates of poverty (p = 0.01), adults without diplomas (p < 0.01), and unemployment (p < 0.01) were highest in the OH group while job growth (p = 0.02) and median income ratio (p < .01) were highest in the RH group. The LH group had a greater proportion of privately insured patients than Medicaid/ uninsured patients (43.4% vs 15.9%, p < 0.01). The most important variables identified by our RF model were job growth (for RH), insurance type (for LH), and no high school diploma (for OH). Insurance type, job growth, and educational attainment may influence operative approach and can contribute to the existing disparities in hernia surgery. Surgeons should address these inequalities and commit to parity in the delivery of surgical care.

This text provides the in-depth understanding of the mechanisms that guide coding and reimbursement. The text is meant to be useful to surgeons in practice, both in general surgery and in surgical sub

To study the effects of fatigue on general surgery residents’ performance on the da Vinci Skills Simulator (dVSS).

trauma typically involves every organ system and requires both the medical and surgical expertise of the attending surgeon. As trauma care has evolved, intensive, nonoperative care has been used more frequently to manage many trauma patients. Consequently, coding for the care of trauma patients is now a more complicated process because it involves knowing not only the major surgical procedure codes, but also how to use evaluation and management (E/M) codes effectively. E/M coding remains an area of difficulty for some surgeons due to the numerous rules and guidelines. Furthermore, Medicare’s decision to not reimburse consultation codes has made coding for E/M services in trauma care even more complicated for those surgeons using the consult codes. this column provides coding guidance and clinical scenarios on the appropriate use of E/M codes during the care of injured or critically ill patients, including the use of critical care codes, the coordination/counseling guide as a coding alternative to the tradition documentation guidelines (“bullets”), and modifiers for coding during the global surgical period.

The Centers for Medicare & Medicaid Services (CMS) has again identified the potential overuse and misuse of Current Procedural Terminology (CPT®) code modifier 25. In the recently published proposed rule for the calendar year (CY) 2017 Medicare Physician Fee Schedule, CMS indicates that its CY 2015 Medicare claims review shows that 19 percent of the codes that describe 0-day global services were billed more than 50 percent of the time, with an evaluation and management (E/M) service with modifier 25 appended. CMS maintains that the routine billing of separate E/M services may indicate a possible problem with the valuation of the procedure codes, which are intended to include all of the routine care associated with the procedure. The agency has identified a number of high-volume codes to review for possible duplication of resources and overvaluation.1 This issue has been raised on multiple occasions since 2005, when the Office of the Inspector General (OIG) published an analysis showing that 35 percent of Medicare claims for modifier 25 did not meet Medicare program requirements.2 Since then, CMS and private payors have increased their scrutiny of codes reported with this modifier, sometimes resulting in significant repayment to Medicare. For example, earlier this year, the U.S. Attorney’s Office for the Northern District of Georgia reached a settlement with a dermatology practice to pay $1.9 million to settle claims that they violated the False Claims Act by billing Medicare for E/M services that were prohibited under Medicare rules.3 To understand why modifier 25 is under this type of scrutiny, surgeons need to understand how its use is defined. Simply put, modifier 25 is appended to an E/M code when a procedure and a separate and significant E/M service is performed by the same physician during the same session or on the same date.4 For example, an established patient comes to your office with a suspicious lesion and, based on your assessment, you decide to excise it. You wonder if you can report an E/M code with modifier 25 appended, as well as the minor procedure code for excising the lesion. The definition of what is “separate and significant” is at the heart of whether both an E/M *All specific references to CPT (Current Procedural Terminology) codes and descriptions are © 2015 American Medical Association. All rights reserved.

Most statistical inferences, which are essential for decision making and research in the area of biomedical sciences, are valid only under certain assumptions. One of the important assumptions in the literature is the symmetry of the underlying distribution of a study population. Several tests of symmetry are found in the literature. Most of these tests suffer from low statistical power which fails to detect a small but meaningful asymmetry in the population. Many investigators have attempted to improve the power of some of these tests. This paper examines several ranked set sample designs for the runs test of symmetry. Our investigation reveals that an optimal ranked set sample design for runs test of symmetry is the extreme ranked set sample (extreme ordered statistics sampling) (ERSS). This design of sampling increases the power and improves the performance of the runs test of symmetry and hence reduces the sample size needed in the study and the cost of the study. Intensive simulation is conducted to examine the power of the proposed optimal design for small sample sizes. Finally, base deficit values for patients subject to either blunt trauma or penetrating trauma are used to illustrate the procedures developed in this paper.

PURPOSE:In response to the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour workweek, the night float coverage model was one system created to comply with the work-hour restriction. However, concern has risen as to the operative case volume achieved with this model. The purpose of this study is to determine which system of call (night float vs traditional rotating call) provided the senior surgical resident with the greatest surgical case volume while in compliance with the 80-hour workweek.METHODS:A nonrandomized sequential study to evaluate the ACGME surgical operative logs (SOLs) for surgical chief residents at Memorial University Medical Center (MUMC), which is a level 1 trauma center, from 2006 to 2008 was conducted. The night float system (NFS) consisted of a PGY-4 or -5 assigned to in-house general surgery and trauma call from 6:00 pm to 6:00 am Monday through Friday morning and a 24-hour shift from 6:00 am on Sunday to 6:00 am Monday morning. Two months of night call rotations (nights) are performed each year per resident with the other 10 months devoted to daytime rotations (days). Conversely, the traditional rotating call schedule (TCS) placed each resident on-call every sixth night for a 30-hour period. The TCS required the resident to average approximately 3 weekday and 2 weekend calls per month. The data examined include all cases on the ACGME SOL submitted by each PGY-4 and 5 residents over a 2-year span. Specific designation of cases between night and day rotations was evaluated while on the NFS, and the total cases volume performed on the NFS and the TCS were analyzed.RESULTS:An evaluation of the 2006-2007 (NFS) year demonstrates an average of 16 cases per month while on nights as compared with 20 cases per month while on day rotations. The caseload on the night rotation was less than day rotations at the PGY-4/5 level. An analysis of the 2006-2007 (NFS) and 2007-2008 (TCS) for PGY-4/5 residents revealed an average total caseload of 224 and 276, respectively. A statistically significant total case difference of 52 cases over the entire year between the 2 systems of call was appreciated.CONCLUSIONS:Because of the work-hour restrictions, maximizing surgical education has become a necessity. With the various call systems used throughout general surgery programs, this study specifically compares a traditional 1-in-6 call schedule versus an NFS. Senior residents lost significant operative experience while operating under an NFS as compared with a TCS. Evidence suggests that the more hours spent by a chief resident during normal operative time elicits more operative experience.