BACKGROUND: CPT valuation historically treated open and minimally invasive (MIS) abdominopelvic operations as interchangeable services performed on similar patients. As MIS has become the dominant approach, open operation may now represent a distinct and more complex clinical scenario. This study characterized contemporary open operation for common abdominopelvic procedures. STUDY DESIGN: The 2023 American College of Surgeons NSQIP database was analyzed for appendectomy, cholecystectomy, right colectomy, low anterior resection, and Hartmann’s procedure. Cases were categorized as MIS, straight to open, or conversion to open. Patient characteristics, operative time, length of stay, and 30-day complications were compared across approaches using binomial regression models. RESULTS: Among 105,085 operations, MIS predominated for appendectomy (98%), cholecystectomy (98%), low anterior resection (84%), and right colectomy (72%), whereas Hartmann’s procedures were primarily open (77%). Conversions represented approximately half of open appendectomies and cholecystectomies and had the longest operative times, exceeding MIS operations by 147% for appendectomy and 116% for cholecystectomy. Compared with MIS, straight-to-open appendectomy was associated with increased length of stay (incident rate ratio 2.92) and higher complication odds (odds ratio 4.02), with conversion-to-open appendectomy showing further stepwise increases (incident rate ratio 4.85; odds ratio 7.07). Similar stepwise patterns from MIS to straight-to-open to conversion-to-open were observed across procedures. CONCLUSIONS: In contemporary practice, open abdominopelvic operations are uncommon and frequently represent conversion from MIS, identifying a subgroup with longer operations, longer hospitalization, and higher complication rate. Current CPT coding and work relative value units may not reflect the greater clinical complexity and effort associated with these cases, supporting reconsideration of open procedure valuation.

BACKGROUND:The Centers for Medicare & Medicaid Services has proposed reducing the work relative value unit valuations for most surgical procedures by 2.5% through an efficiency adjustment based on the assumption that surgical work and operative length have decreased over time. Whether the length and complexity of surgical procedures have decreased or increased is unknown. Empirical data on trends in surgical length and complexity are needed to guide evidence-based regulations by federal policymakers. STUDY DESIGN:The NSQIP registry was analyzed in 2019 and 2023. Analysis was performed at the CPT level and limited to codes with at least 1,000 underlying cases. The primary outcome was surgical efficiency, defined as skin-to-skin operative time. Secondary outcomes were measures of patient complexity, including preoperative risk factors (eg age, comorbidities) and 30-day morbidity and mortality. RESULTS:The sample included 1,704,311 operations across 249 CPT codes and 11 surgical specialties. Collectively, these codes accounted for $3.2B in fee-for-service Medicare spending in 2023. Overall, operative times increased by 3.1% (95% CI 3.0% to 3.3%, p < 0.001) in 2023 compared with 2019, or 0.8% per year (95% CI 0.7% to 0.8% per year, p < 0.001). At the procedure level, 90% of CPT codes had longer or similar operative times in 2023 compared with 2019. Statistically, all measures of complexity also increased during the study time period, without a change in operative mortality. CONCLUSIONS:For the majority of surgical procedures, operative times have stayed the same or increased from 2019 to 2023. Patient complexity also correspondingly increased. The rationale for an efficiency adjustment to the Medicare physician fee schedule for surgical procedures is not supported by objective data from a national surgical registry.

Low-titer "O" negative whole blood (LTOWB) is efficacious in hemorrhage, but adoption of this resource has lagged other advances in our Arkansas Trauma System. Of the 57 trauma centers (TCs) in our system, only 2 use LTOWB. Reasons for TCs not using LTOWB are concerns of cost and wastage acting as barriers for adoption. Our Level III TC was the first in our state to use LTOWB and developed pathways to promote efficient usage and avoid wastage. From 2022 to 2024, our TC transfused 2859 units of RBCs to 1372 patients, with 124 patients receiving 190 units of LTOWB. Our blood bank achieved zero wastage of our supply of LTOWB, with 93% of LTOWB being used without conversion and 7% being converted to RBCs. We hope our methodology to conserve LTOWB by protocols without incurring additional costs to supply LTOWB versus standard balanced transfusion will serve as impetus for expanded usage.

Importance:There are 3 Current Procedural Terminology (CPT) codes for appendectomy-2 codes describing open appendectomy with or without peritonitis or abscess and 1 code for laparoscopic appendectomy regardless of presentation-which have remained the same for more than 30 years. It is possible that physician work (assessed in work relative value units) for these codes will eventually need to be reassessed, and this study may provide an opportunity for modernizing the CPT codes and their descriptions. Objective:To provide empirical data to determine what a new code structure for appendectomy could look like. Design, Setting, and Participants:This cross-sectional study performed a retrospective review of 2021-2023 US National Surgical Quality Improvement Program (NSQIP) adult and pediatric appendectomy-specific files among adults and children undergoing appendectomy. Data analysis was completed in May 2025. Main Outcome and Measures:We sought to identify distinct populations of patients that require different levels of surgeon work, which we measured using operative time, postoperative length of stay, and rates of complications. Results:The final sample included 110 379 encounters for appendectomy. Approximately one-quarter (28 583 [25.9%]) had complicated disease; only 3057 cases (2.8%) were performed open. Compared to uncomplicated appendicitis in children and adults (aged 6-64 years), we found the following factors were significantly associated with changes (generally increases) in surgeon work using our measures: complicated disease, age 5 years or younger and 65 years or older, and whether the procedure was for interval appendectomy or performed for tumor. Based on these stratifying variables, we propose 16 new codes-8 laparoscopic and 8 open-that identify unique populations of patients undergoing appendectomy with different work profiles. Conclusions and Relevance:In this cross-sectional study, we provide the first empirical strategy for identifying new codes for appendectomy using objective measures of surgeon work. If appendectomy ever undergoes review of its relative work, this study provides a potential framework for improving the CPT codes and describing the nuances of appendectomy in the modern era.

BACKGROUND: The state legislature codified and funded the Arkansas Trauma System (ATS) in 2009. Quarterly preventable mortality reviews (PMRs) by the ATS began in 2015 and were used to guide state-wide targeted education to reduce preventable or potentially preventable (P/PP) deaths. We present the results of this PMR-education initiative from 2015 to 2022. STUDY DESIGN: The ATS uses a statistical sampling model of the Arkansas Trauma Registry to select ~40% of the deaths for quarterly review, reflecting the overall the Arkansas Trauma Registry mortality population. A multispecialty PMR committee reviews the medical records from prehospital care to death, and hospital and regional advisory council reviews for each death. The PMR committee assigns opportunities for improvement (OFIs), cause(s) of death, and the likelihood of preventability for each case. Education to improve trauma care includes annual state-wide trauma meetings, novel classes targeted at level III/IV trauma center hospital providers, trauma evidence–based guidelines, and PMR “pearls.” RESULTS: We reviewed 1,979 deaths with 211 (10.6%) deaths judged to be P/PP deaths. There was a progressive decrease in P/PP deaths and OFIs for P/PP deaths. Five OFI types targeted by education accounted for 72% of the 24 possible OFI types in the P/PP cases, and 94% of the “contributory OFIs.” Reductions in “delay in treatment” resulted in the most rapid decrease in P/PP deaths. CONCLUSIONS: Using ongoing PMR studies to target provider education led to a reduction in P/PP deaths and OFIs for P/PP deaths. Focusing on education designed to improve preventable mortality can result in a substantial decrease in P/PP deaths by 43% (14% to 8%) for trauma systems.

BACKGROUND:Clinical early warning scoring systems, have improved patient outcomes in a range of specializations and global contexts. These systems are used to predict patient deterioration. A multitude of patient-level physiological decompensation data has been made available through the widespread integration of early warning scoring systems within EHRs across national and international health care organizations. These data can be used to promote secondary research. The diversity of early warning scoring systems and various EHR systems is one barrier to secondary analysis of early warning score data. Given that early warning score parameters are varied, this makes it difficult to query across providers and EHR systems. Moreover, mapping and merging the parameters is challenging. We develop and validate the Early Warning System Scores Ontology (EWSSO), representing three commonly used early warning scores: the National Early Warning Score (NEWS), the six-item modified Early Warning Score (MEWS), and the quick Sequential Organ Failure Assessment (qSOFA) to overcome these problems.METHODS:We apply the Software Development Lifecycle Framework-conceived by Winston Boyce in 1970-to model the activities involved in organizing, producing, and evaluating the EWSSO. We also follow OBO Foundry Principles and the principles of best practice for domain ontology design, terms, definitions, and classifications to meet BFO requirements for ontology building.RESULTS:We developed twenty-nine new classes, reused four classes and four object properties to create the EWSSO. When we queried the data our ontology-based process could differentiate between necessary and unnecessary features for score calculation 100% of the time. Further, our process applied the proper temperature conversions for the early warning score calculator 100% of the time.CONCLUSIONS:Using synthetic datasets, we demonstrate the EWSSO can be used to generate and query health system data on vital signs and provide input to calculate the NEWS, six-item MEWS, and qSOFA. Future work includes extending the EWSSO by introducing additional early warning scores for adult and pediatric patient populations and creating patient profiles that contain clinical, demographic, and outcomes data regarding the patient.

Introduction The Arkansas Trauma System was established by law more than a dozen years ago, and all participating trauma centers are required to maintain red blood cells. Since then, there has been a paradigm shift in resuscitating exsanguinating trauma patients. Damage Control Resuscitation with balanced blood products (or whole blood) and minimal crystalloid is now the standard of care. This project aimed to determine access to balanced blood products in our state's Trauma System (TS). Methods A survey of all trauma centers in the Arkansas TS was conducted, and geospatial analysis was performed. Immediately Available Balanced Blood (IABB) was defined as at least 2 units (U) of thawed plasma (TP) or never frozen plasma (NFP), 4 units of red blood cells (RBCs), 2 units of fresh frozen plasma (FFP), and 1 unit of platelets or 2 units of whole blood (WB). Results All 64 trauma centers in the state TS completed the survey. All level I, II, and III Trauma Centers (TCs) maintain RBC, plasma, and platelets, but only half of the level II and 16% of the level III TCs have thawed or never frozen plasma. A third of level IV TCs maintain only RBCs, while only 1 had platelets, and none had thawed plasma. 85% of people in our state are within 30 min of RBCs, almost two-thirds are within 30 min of plasma (TP, NFP, or FFP) and platelets, while only a third are within 30 min of IABB. More than 90% are within an hour of plasma and platelets, while only 60% are within that time from an IABB. The median drive times for Arkansas from RBC, plasma (TP, NFP, or FFP), platelets, and an immediately available and balanced blood bank are 19, 21, 32, and 59 minutes, respectively. A lack of thawed or non-frozen plasma and platelets are the most common limitations of IABB. One level III TC in the state maintains WB, which would alleviate the limited access to IABB. Conclusion Only 16% of the trauma centers in Arkansas can provide IABB, and only 61% of the population can reach IABB within 60 minutes. Opportunities exist to reduce the time to balanced blood products by selectively distributing WB, TP, or NFP to hospitals in our state trauma system.

We studied changes over time in professional physician work relative value units (wRVUs) as well as changes in the Medicare payment per RVU, called the conversion factor (CF), with the hypothesis that reimbursements for vascular care have not kept up with inflation. RVUs and CFs were derived from published Medicare Physician Fee Schedules. Total RVUs (tRVUs) = wRVUs + practice expense RVUs + malpractice RVUs. Medicare payment is tRVU multiplied by CF. When the Resource-Based Relative Value Scale (RBRVS) began in 1992, the CF was $31. The Centers for Medicare and Medicaid Services updates the CF annually. An inflation adjustment was applied to compare 2019 payments to the 1992 base year payment using the U.S. Bureau of Labor Consumer Price Index. Vascular RVUs and payments were compared with commonly performed procedures from other specialties. Vascular wRVUs were uniformly undervalued in the original RBRVS because no vascular surgeons were allowed to participate in the underlying research. Subsequent efforts by The Society for Vascular Surgery to bring vascular wRVUs to parity were successful for many procedures. Using time and intensity surveys, carotid endarterectomy underwent reevaluation with a 24% increase in wRVUs. Medicare payment for carotid endarterectomy was $1093 in 1992 and is $1182 in 2019 (Fig 1). Despite the wRVU increase, the inflation adjusted 2019 payment is only $650 in 1992 dollars, a 41% pay cut. Likewise, wRVUs for an arteriovenous fistula increased 35%, but adjusted payment decreased by 32%. Open abdominal aortic aneurysms wRVUs increased 53%, but payment decreased by 33%. Femoral-distal wRVUs increased 98%, but adjusted payment decreased by 27%. Underlying all inflation-adjusted payment reductions is the Medicare CF, which decreased by 36% compared with the 1992 RBRVS base year (Fig 2). For other specialties, procedures with wRVU reductions (cataract wRVU -18%) or procedures with no wRVU change (total knee), experienced even more precipitous pay cuts, -62% and -57%, respectively. From 1992 to 2019, vascular wRVUs increased 24% to 98%, but inflation-adjusted Medicare payments decreased by 27% to 41%. This paradox is due to the insidious yearly failure of the Medicare CF to keep pace with inflation. Physicians have no control over the CF. In fact, the 2015 Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act locks the CF at 0% until 2025, so without congressional action, professional payments will continue to decrease.Fig 2Medicare conversion factor (CF), actual versus inflation-adjusted payment for 1 relative value unit (RVU): actual (blue) and inflation adjusted to 1992 dollars (red).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objective: Medicare reimbursements are standardized nationwide on the basis of resource-dependent inputs of physicians' time, intensity, practice costs, and malpractice costs, whereas Medicaid payments vary and are determined by individual states. Our objectives were to determine Medicaid reimbursement to physicians for common vascular procedures for the seven states in the Northeast that compose the New England Society for Vascular Surgery and to compare Medicaid payments with Medicare. Methods: Using publicly available data, we obtained Medicaid physician payments in Connecticut, Massachusetts, Maine, New Hampshire, New York, Rhode Island, and Vermont for 10 commonly performed vascular surgery procedures. For comparison, Medicare physician payments for these procedures were adjusted for regional differences using Medicare geographic payment cost indices. Descriptive statistics were calculated by state; Wilcoxon signed rank test was used to compare fees, and one-way analysis of variance was used to compare variance. Results: Medicaid payments varied widely by state. Within individual states (except Vermont), there was no relationship between Medicaid and Medicare payments. Medicaid reimbursement for common vascular procedures ranged from 25% to 91% of Medicare rates and had up to a threefold variation in payment among states for a single procedure. The mean Medicaid payment was 60% of Medicare payment. The greatest state-to-state variance in payment was for open abdominal aortic repair (standard deviation, $227.31); the least was for femoral artery exposure (standard deviation, $31.86). For a Medicaid-based, frequency-weighted analysis of services, New Hampshire exhibited the lowest payments (43% Medicare) and Vermont the highest (80% Medicare). Conclusions: Among the seven Northeast states considered, with the exception of Vermont, there is no logical relationship between Medicaid and Medicare payments. Because Medicare payments are determined by the Centers for Medicare and Medicaid Services with consideration of resource-based inputs, we conclude that in six of the seven states, Medicaid payments bear no relationship to resource utilization. With Medicaid expansion, access to vascular procedures may be limited by payments insufficient to meet resource needs.

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.

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

BACKGROUND: Both the Medicare (MCR) and Medicaid (MCD) programs turn 50 this year. Medicare has developed a national resource-based payment methodology for physicians' services, with broad input by specialty societies, and MCD payments are set by individual states by various means.STUDY DESIGN: We have conducted the first national comparison of payment methodology of MCD vs MCR for procedures commonly delivered by general surgeons. Using the most recent Centers for Medicare and Medicaid Services' Medicare data for frequency of allowed charges for general surgeons, we selected the most frequently billed procedures and gathered data from the 50 states for MCD and MCR payments. We determined the "Medicaid discount" (MCD payment minus MCR payment) expressed as dollars and percent, as well as dollars paid per relative value of work.RESULTS: We have discovered wide variations in MCD payments among states for the same procedures, demonstrating unexplained "discounts" of MCD payments in relationship to MCR. We found that MCD payments show wide variations across the states, with many states paying far less than MCR for common, essential procedures.CONCLUSIONS: These findings call into question the fairness of MCD reimbursement for general surgery services in the United States. This discount to MCR could act as a disincentive for surgeons to care for some patients, based on the state of residence. These unexplained discounts could have considerable long-term effects for patients dependent on the MCD program. Our study should act as a stimulus for states to examine their payment methodologies to provide more uniform and fairer payments for surgical procedures. (J Am Coll Surg 2016; 222: 387-394. (C) 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

BACKGROUND:There have been no comprehensive studies across an organized statewide trauma system using a standardized method to determine cost. STUDY DESIGN:Trauma financial impact includes the following costs: verification, response, and patient care cost (PCC). We conducted a survey of participating trauma centers (TCs) for federal fiscal year 2012, including separate accounting for verification and response costs. Patient care cost was merged with their trauma registry data. Seventy-five percent of the 2012 state trauma registry had data submitted. Each TC's reasonable cost from the Medicare Cost Report was adjusted to remove embedded costs for response and verification. Cost-to-charge ratios were used to give uniform PCC across the state. RESULTS:Median (mean ± SD) costs per patient for TC response and verification for Level I and II centers were $1,689 ($1,492 ± $647) and $450 ($636 ± $431) for Level III and IV centers. Patient care cost-median (mean ± SD) costs for patients with a length of stay >2 days rose with increasing Injury Severity Score (ISS): ISS <9: $6,787 ($8,827 ± $8,165), ISS 9 to 15: $10,390 ($14,340 ± $18,395); ISS 16 to 25: $15,698 ($23,615 ± $21,883); and ISS 25+: $29,792 ($41,407 ± $41,621), and with higher level of TC: Level I: $13,712 ($23,241 ± $29,164); Level II: $8,555 ($13,515 ± $15,296); and Levels III and IV: $8,115 ($10,719 ± $11,827). CONCLUSIONS:Patient care cost rose with increasing ISS, length of stay, ICU days, and ventilator days for patients with length of stay >2 days and ISS 9+. Level I centers had the highest mean ISS, length of stay, ICU days, and ventilator days, along with the highest PCC. Lesser trauma accounted for lower charges, payments, and PCC for Level II, III, and IV TCs, and the margin was variable. Verification and response costs per patient were highest for Level I and II TCs.

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