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Trauma, and Genital and Urethral Reconstruction
Urological Survey
Trauma, and Genital and Urethral Reconstruction Are Urologists Fairly Reimbursed for Complex Procedures: Failure of 22 Modifier? Y. Lotan, A. Bagrodia, C. G. Roehrborn and J. Scott Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas Urology 2008; 72: 494 – 497.
Objectives: The 22 modifier was designed to provide surgeons with additional reimbursement for performing complex procedures. We evaluated whether urologists at a tertiary referral center are reimbursed when using the 22 modifier. Methods: We evaluated the charts and billing data of all adult urology noncharity cases using the 22 modifier from January 2006 and September 2007. Results: The 22 modifier was used in 317 of 7494 (4.2%) unique procedures performed. Of these 317 procedures, 99 (31%) were reimbursed at a greater rate than the contract level, with a mean increase greater than the contract of $388 (median $260, range $62–$3524), for a mean of 28% greater than the contract. Of the 317 cases, 114 were within $50 of the contract level and 104 were reimbursed at less than the contract level. Additionally, 56 cases were paid at the initial request and ⬍ or ⫽ 4 appeals were sent in 228 cases, with a successful result in 57 (25%). When analyzed by payor (n ⫽ 289), private insurance paid 81 of 187 (43.3%), Medicare paid 23 of 95 (24.2%), and Medicaid paid 1 of 7 (14.3%). Most payments took ⬎ 2 months to be paid. The reasons for using the 22 modifier code included extensive surgery, previous surgery, staghorn calculus, extended lymphadenectomy for bladder cancer, adhesions, difficult anatomy, complex dissection, morbid obesity, previous chemotherapy, scarring, previous radiotherapy, difficult debulking, and pregnancy. Of the 317 cases, ⬎ 121 had several confounding factors. Conclusions: The 22 modifier does not provide consistent reimbursement for urologists performing complex procedures. The long-term implications of financial disincentives to performing difficult surgeries need to be further evaluated. Editorial Comment: This article shows that urologists are not being reimbursed fairly when using the 22 modifier—the code used to designate a difficult or unusual procedure. Complicating features such as previous surgeries, radiotherapy, obesity and/or complex anatomy all require use of the 22 modifier to obtain additional reimbursement for the additional time and effort spent in the operating room. This analysis of 317 cases reveals that additional payments were granted only 31% of the time, despite the fact that this code was used in a meager 4.2% of the 7,494 cases during the study period. I suspect that use of the 22 modifier is warranted in far more than 4% of reconstructive cases performed at most tertiary referral centers. Advanced urethral strictures often require combinations of techniques for successful 1-stage reconstruction. In this series of 22 modifier coded cases only 30% of urethroplasty procedures were reimbursed additionally, and that reimbursement was only 22% more than contract. Reconstructive urologists should be certain to use the 22 modifier whenever applicable, and also to bill for oral mucosa graft harvesting procedures as appropriate. Allen F. Morey, M.D.
0022-5347/09/1814-1747/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 181, 1747-1750, April 2009 Printed in U.S.A. DOI:10.1016/j.juro.2008.12.047
www.jurology.com
1747
1748
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
Posttraumatic Posterior Urethral Strictures in Children—Management and Intermediate-Term Follow-Up in Tertiary Care Center M. Singla, M. S. Jha, K. Muruganandam, A. Srivastava, M. S. Ansari, A. Mandhani, D. Dubey and R. Kapoor Department of Urology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India Urology 2008; 72: 540 –544.
Objectives: To evaluate the management and intermediate-term follow-up of posttraumatic posterior urethral strictures in children. Methods: From March 2000 to November 2006, the surgical records of 28 children (⬍ or ⫽ 18 years) who had been admitted for treatment of posttraumatic posterior urethral strictures were retrospectively reviewed. The patients had been followed up for a median of 36 months (range 3–58). The cause of trauma, extent of urinary tract injury, radiologic examination findings, previous treatment, and its effect on the final outcome, treatment complications,, and failures were evaluated. Results: The mean age of the patients was 12.1 years (range 5–18) at the injury. The estimated radiographic mean stricture length before surgery was 3.41 cm (range 2– 6). Of the 28 patients, 27 were treated with transperineal anastomotic urethroplasty, with a success rate of 75%. All treatment failures were at the anastomotic site and occurred within the first year of anastomotic urethroplasty. The failed repairs (7 cases) were successfully managed endoscopically in 4 patients and by redo urethroplasty in 3, for a final success rate of 100%. Of the 28 patients, 15 (80%) with urethral manipulation before anastomotic urethroplasty had a satisfactory result compared with 69.3% of patients without previous surgical treatment. The difference was not statistically significant. Conclusions: Most posttraumatic posterior urethral strictures in children can be managed through the perineal route. The transpubic approach should be reserved for more complex posterior strictures. Previous urethral manipulations did not affect the intermediate-term results of anastomotic urethroplasty. Editorial Comment: The authors report a series of 28 children undergoing reconstruction of pelvic fracture urethral distraction defects. An initial success rate of 75% was reported, and after 7 underwent a subsequent procedure an ultimate success rate of 100% was noted. The authors observe that an additional retropubic dissection is occasionally helpful to expose the prostatic apex for perineal reconstruction and, as I have found in many similar cases, to remove concomitant large bladder stones. As Jordan correctly remarks in the accompanying editorial comment, extreme caution should be used in prepubertal boys, since the genital tissues are much less robust and forgiving compared with those in adults. Allen F. Morey, M.D.
High-Flow Priapism: Superselective Cavernous Artery Embolization With Microcoils B. X. Liu, Z. C. Xin, Y. H. Zou, L. Tian, Y. G. Wu, X. J. Wu, W. D. Song, Z. C. Zhang and B. Gao Andrology Center, and Department of Interventional Radiology and Vascular Surgery, First Hospital, Peking University, Beijing, China Urology 2008; 72: 571–574.
Objectives: To determine the effectiveness of superselective cavernous artery embolization. Methods: Eight patients with high-flow priapism were included in this study. All were treated by superselective cavernous artery embolization with microcoils and gelatin sponges. The follow-up examinations consisted of color duplex ultrasonography. The International Index of Erectile Function 5-item questionnaire was used to investigate the patients’ erectile function before the onset of priapism, at embolization, and 6 months after embolization. Results: A unilateral cavernous fistula was found in 7 patients and bilateral fistulas in 1. Of the 8 patients, 2 (1 with unilateral and 1 with bilateral fistulas) initially underwent embolization with a gelatin sponge but presented with recurrence of tumescence 1 week after treatment and required a repeat embolization procedure with microcoils.
IMAGING
1749
The other 6 patients (75%) were successfully detumescent after embolization with microcoils. The 6 patients (75%) who underwent embolization with microcoils alone had normal erectile function with a mean International Index of Erectile Function score of 22.20 at 6 months after embolization. The 2 patients (25%) who had required repeat embolization had erectile dysfunction, with a mean International Index of Erectile Function score of 13.00. Conclusions: Superselective cavernous artery embolization with microcoils is a safe and effective treatment of high-flow priapism. The use of microcoils resulted in greater embolization success and preservation of erectile function, especially in the treatment of a unilateral arterial fistula in a young patient. Editorial Comment: These authors from Beijing report their experience with superselective cavernous artery embolization for high flow priapism. Their results demonstrate that use of gelatin sponge for embolization is associated with early recurrent tumescence. However, use of microcoils yielded effective initial detumescence without subsequent erectile dysfunction 6 months later. Allen F. Morey, M.D.
Imaging Which Study When? Iodinated Contrast-Enhanced CT Versus Gadolinium-Enhanced MR Imaging R. A. Halvorsen Department of Radiology, MCV Hospitals/VCU Medical Center, Richmond, Virginia Radiology 2008; 249: 9 –15.
No Abstract
Which Study When? Is Gadolinium-Enhanced MR Imaging Safer Than Iodine-Enhanced CT? J. C. Weinreb Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut Radiology 2008; 249: 3– 8.
No Abstract Editorial Comment: These 2 articles were published back-to-back in Radiology. Both authors discuss in detail the risks and benefits of iodinated and gadolinium based contrast material, and weigh the relative risk of contrast induced nephrotoxicity from iodinated contrast material against the risk of nephrogenic systemic fibrosis from gadolinium based magnetic resonance contrast material. Both authors do a thorough job. The current consensus is that patients with renal insufficiency are at increased risk for contrast induced nephrotoxicity and nephrogenic systemic fibrosis. As renal function declines, the risk of nephrogenic systemic fibrosis increases. Besides severity of renal impairment, 2 additional important factors should be considered when deciding to administer gadolinium based contrast material, namely estimation of the total lifetime dose of gadolinium and the presence or absence of a severe inflammatory event at the time that the gadolinium will be administered. In patients with an estimated glomerular filtration rate (GFR) of less than 15 ml per minute and those undergoing dialysis iodinated contrast material is preferred and gadolinium based contrast medium is contraindicated. In patients with an estimated GFR of 15
Trauma, and Genital and Urethral Reconstruction Are Urologists Fairly Reimbursed for Complex Procedures: Failure of 22 Modifier? Y. Lotan, A. Bagrodia, C. G. Roehrborn and J. Scott Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas Urology 2008; 72: 494 – 497.
Objectives: The 22 modifier was designed to provide surgeons with additional reimbursement for performing complex procedures. We evaluated whether urologists at a tertiary referral center are reimbursed when using the 22 modifier. Methods: We evaluated the charts and billing data of all adult urology noncharity cases using the 22 modifier from January 2006 and September 2007. Results: The 22 modifier was used in 317 of 7494 (4.2%) unique procedures performed. Of these 317 procedures, 99 (31%) were reimbursed at a greater rate than the contract level, with a mean increase greater than the contract of $388 (median $260, range $62–$3524), for a mean of 28% greater than the contract. Of the 317 cases, 114 were within $50 of the contract level and 104 were reimbursed at less than the contract level. Additionally, 56 cases were paid at the initial request and ⬍ or ⫽ 4 appeals were sent in 228 cases, with a successful result in 57 (25%). When analyzed by payor (n ⫽ 289), private insurance paid 81 of 187 (43.3%), Medicare paid 23 of 95 (24.2%), and Medicaid paid 1 of 7 (14.3%). Most payments took ⬎ 2 months to be paid. The reasons for using the 22 modifier code included extensive surgery, previous surgery, staghorn calculus, extended lymphadenectomy for bladder cancer, adhesions, difficult anatomy, complex dissection, morbid obesity, previous chemotherapy, scarring, previous radiotherapy, difficult debulking, and pregnancy. Of the 317 cases, ⬎ 121 had several confounding factors. Conclusions: The 22 modifier does not provide consistent reimbursement for urologists performing complex procedures. The long-term implications of financial disincentives to performing difficult surgeries need to be further evaluated. Editorial Comment: This article shows that urologists are not being reimbursed fairly when using the 22 modifier—the code used to designate a difficult or unusual procedure. Complicating features such as previous surgeries, radiotherapy, obesity and/or complex anatomy all require use of the 22 modifier to obtain additional reimbursement for the additional time and effort spent in the operating room. This analysis of 317 cases reveals that additional payments were granted only 31% of the time, despite the fact that this code was used in a meager 4.2% of the 7,494 cases during the study period. I suspect that use of the 22 modifier is warranted in far more than 4% of reconstructive cases performed at most tertiary referral centers. Advanced urethral strictures often require combinations of techniques for successful 1-stage reconstruction. In this series of 22 modifier coded cases only 30% of urethroplasty procedures were reimbursed additionally, and that reimbursement was only 22% more than contract. Reconstructive urologists should be certain to use the 22 modifier whenever applicable, and also to bill for oral mucosa graft harvesting procedures as appropriate. Allen F. Morey, M.D.
0022-5347/09/1814-1747/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 181, 1747-1750, April 2009 Printed in U.S.A. DOI:10.1016/j.juro.2008.12.047
www.jurology.com
1747
1748
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
Posttraumatic Posterior Urethral Strictures in Children—Management and Intermediate-Term Follow-Up in Tertiary Care Center M. Singla, M. S. Jha, K. Muruganandam, A. Srivastava, M. S. Ansari, A. Mandhani, D. Dubey and R. Kapoor Department of Urology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India Urology 2008; 72: 540 –544.
Objectives: To evaluate the management and intermediate-term follow-up of posttraumatic posterior urethral strictures in children. Methods: From March 2000 to November 2006, the surgical records of 28 children (⬍ or ⫽ 18 years) who had been admitted for treatment of posttraumatic posterior urethral strictures were retrospectively reviewed. The patients had been followed up for a median of 36 months (range 3–58). The cause of trauma, extent of urinary tract injury, radiologic examination findings, previous treatment, and its effect on the final outcome, treatment complications,, and failures were evaluated. Results: The mean age of the patients was 12.1 years (range 5–18) at the injury. The estimated radiographic mean stricture length before surgery was 3.41 cm (range 2– 6). Of the 28 patients, 27 were treated with transperineal anastomotic urethroplasty, with a success rate of 75%. All treatment failures were at the anastomotic site and occurred within the first year of anastomotic urethroplasty. The failed repairs (7 cases) were successfully managed endoscopically in 4 patients and by redo urethroplasty in 3, for a final success rate of 100%. Of the 28 patients, 15 (80%) with urethral manipulation before anastomotic urethroplasty had a satisfactory result compared with 69.3% of patients without previous surgical treatment. The difference was not statistically significant. Conclusions: Most posttraumatic posterior urethral strictures in children can be managed through the perineal route. The transpubic approach should be reserved for more complex posterior strictures. Previous urethral manipulations did not affect the intermediate-term results of anastomotic urethroplasty. Editorial Comment: The authors report a series of 28 children undergoing reconstruction of pelvic fracture urethral distraction defects. An initial success rate of 75% was reported, and after 7 underwent a subsequent procedure an ultimate success rate of 100% was noted. The authors observe that an additional retropubic dissection is occasionally helpful to expose the prostatic apex for perineal reconstruction and, as I have found in many similar cases, to remove concomitant large bladder stones. As Jordan correctly remarks in the accompanying editorial comment, extreme caution should be used in prepubertal boys, since the genital tissues are much less robust and forgiving compared with those in adults. Allen F. Morey, M.D.
High-Flow Priapism: Superselective Cavernous Artery Embolization With Microcoils B. X. Liu, Z. C. Xin, Y. H. Zou, L. Tian, Y. G. Wu, X. J. Wu, W. D. Song, Z. C. Zhang and B. Gao Andrology Center, and Department of Interventional Radiology and Vascular Surgery, First Hospital, Peking University, Beijing, China Urology 2008; 72: 571–574.
Objectives: To determine the effectiveness of superselective cavernous artery embolization. Methods: Eight patients with high-flow priapism were included in this study. All were treated by superselective cavernous artery embolization with microcoils and gelatin sponges. The follow-up examinations consisted of color duplex ultrasonography. The International Index of Erectile Function 5-item questionnaire was used to investigate the patients’ erectile function before the onset of priapism, at embolization, and 6 months after embolization. Results: A unilateral cavernous fistula was found in 7 patients and bilateral fistulas in 1. Of the 8 patients, 2 (1 with unilateral and 1 with bilateral fistulas) initially underwent embolization with a gelatin sponge but presented with recurrence of tumescence 1 week after treatment and required a repeat embolization procedure with microcoils.
IMAGING
1749
The other 6 patients (75%) were successfully detumescent after embolization with microcoils. The 6 patients (75%) who underwent embolization with microcoils alone had normal erectile function with a mean International Index of Erectile Function score of 22.20 at 6 months after embolization. The 2 patients (25%) who had required repeat embolization had erectile dysfunction, with a mean International Index of Erectile Function score of 13.00. Conclusions: Superselective cavernous artery embolization with microcoils is a safe and effective treatment of high-flow priapism. The use of microcoils resulted in greater embolization success and preservation of erectile function, especially in the treatment of a unilateral arterial fistula in a young patient. Editorial Comment: These authors from Beijing report their experience with superselective cavernous artery embolization for high flow priapism. Their results demonstrate that use of gelatin sponge for embolization is associated with early recurrent tumescence. However, use of microcoils yielded effective initial detumescence without subsequent erectile dysfunction 6 months later. Allen F. Morey, M.D.
Imaging Which Study When? Iodinated Contrast-Enhanced CT Versus Gadolinium-Enhanced MR Imaging R. A. Halvorsen Department of Radiology, MCV Hospitals/VCU Medical Center, Richmond, Virginia Radiology 2008; 249: 9 –15.
No Abstract
Which Study When? Is Gadolinium-Enhanced MR Imaging Safer Than Iodine-Enhanced CT? J. C. Weinreb Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut Radiology 2008; 249: 3– 8.
No Abstract Editorial Comment: These 2 articles were published back-to-back in Radiology. Both authors discuss in detail the risks and benefits of iodinated and gadolinium based contrast material, and weigh the relative risk of contrast induced nephrotoxicity from iodinated contrast material against the risk of nephrogenic systemic fibrosis from gadolinium based magnetic resonance contrast material. Both authors do a thorough job. The current consensus is that patients with renal insufficiency are at increased risk for contrast induced nephrotoxicity and nephrogenic systemic fibrosis. As renal function declines, the risk of nephrogenic systemic fibrosis increases. Besides severity of renal impairment, 2 additional important factors should be considered when deciding to administer gadolinium based contrast material, namely estimation of the total lifetime dose of gadolinium and the presence or absence of a severe inflammatory event at the time that the gadolinium will be administered. In patients with an estimated glomerular filtration rate (GFR) of less than 15 ml per minute and those undergoing dialysis iodinated contrast material is preferred and gadolinium based contrast medium is contraindicated. In patients with an estimated GFR of 15