Response to Letter by Albright et al
Thank you for your interest in our article regarding the geographic distribution of recombinant tissue plasminogen activator treatments by hospital in the United States.1 We agree with the overall sentiment of your letter, which is that physicians should be very aware of the importance of documentation in their clinical care of stroke patients. It is not only important for billing appropriately but also it is extremely important from the public health perspective in the United States for tracking and improving health care delivery.
However, we would like to clarify the difference between the ICD-9 procedure codes vs Common Procedural Terminology codes. Common Procedural Terminology codes document physician time and activities. For example, for an acute thrombolysis case, physicians could bill for Common Procedural Terminology critical care code 99291 for the first 30 to 74 minutes, and then bill for 99292 for each additional 30 minutes of critical care. These codes require documentation that the critical care was provided in person by an attending physician, with the amount of time spent. As an aside, for billing purposes, we usually recommend critical care codes as opposed to consultation evaluation and management codes, because critical care codes have higher rates of reimbursement if critical care was provided.2 In contrast, ICD-9 procedure codes are related to procedures performed in the hospital and are assigned by the hospital coding staff. These do not have the same stringent requirements for time spent or “physician in-person” documentation. Most physicians are likely to be unaware of the specific procedure codes assigned to a given hospital admission by the hospital coding staff. It is the ICD-9 procedure code 99.1 that was used in this analysis, which is defined as “injection or infusion of thrombolytic agent.” We do not expect that fellow or resident administration of recombinant tissue plasminogen activator or lack of physician awareness of the hospital procedural code 99.1 to affect our results in a substantial way.
We also agree that our national estimate of 2.4% of ischemic stroke patients receiving recombinant tissue plasminogen activator is an underestimate. Previously, we have reported that ICD-9 procedure code 99.1 has a lower sensitivity for stroke thrombolysis using an analysis of the Premier database, which cross-references pharmacy drug utilization with administrative data, including all ages of patients. Within this data set, we have reported national rates of recombinant tissue plasminogen activator use of >3% in fiscal year 2007.3 It is because of this limitation that we have not presented actual percentages or raw numbers of treatments by hospital in the current analysis; instead, all data are presented relative to a pooled national average that has the same limitation.
Source of Funding
This work was supported by a grant from the Centers for Disease Control.
D.O.K. has received modest compensation as a speaker for Genentech, Inc.
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