Appendix 4: Cost analysis SOC versus VSI – rotator cuff diagnosis, therapy and surgery
Diagnosis and treatment for rotator cuff - ICD9CM Diagnosis code 8404
Standard of Care versus VSI diagnosis and treatment paradigm - costs using 2013 reimbursement data
Number of diag & ther. procedures performed for ICD9CM Diagnosis code 8404 =
166,191 (derived from TP and FP)
Number of diagnostic procedures performed for ICD9CM Diagnosis code 8404 =
263,311 (derived from FN and TN)
Procedure
code
Description
SOC Cost
Notes
CPT
Evaluation and management - new patient - 30 minutes
$108.19
99203
CPT
Magnetic resonance (e.g. proton) imaging, any joint of upper
$405.21
73221
extremity; without contrast material, non-facility (RVUs of 11.91)
(Global)
CPT
73221-26
Magnetic resonance (e.g. proton) imaging, any joint of upper
extremity; without contrast material, non-facility (RVUs of 1.96)
(Professional component "-26")
CPT
29805
Arthroscopy, shoulder, diagnostic, with or without synovial biopsy
(separate procedure) - nonfacility setting
CPT
20610
Arthrocentesis - aspiration or injection major joint or bursa @ 12.5%
of time for diagnosis (1)
CPT
Arthroscopy, shoulder, surgical; with rotator cuff repair
29827
APC 0042 Hospital outpatient - rotator cuff repair/surgery
CPT
Evaluation and management - existing patient - 30 minutes
99213
Total cost per patient (for positive findings)
Total cost per patient (for neg findings) [diagnostic procedures only)
Number of surgical procedures performed based on positive findings =
Number of surgical procedures performed based on FN MRI findings =
1
VSI Cost
$108.19
$0.00
$66.69
$0.00
$0.00
$479.38
$65.56
$0.00
$1,086.35
$1,086.35
$3,880.22
$72.81
$3,880.22
$72.81
$5,624..71
$585.33
161,191
0
$5,626.95
$587.57
140,763
23,872
(TP+FP)
Notes
(TP)
(FN)
Description
Number of people who are treated (e.g. medical mgmt) due to FN MRI findings=
Total cost to system for diagnosis and treatment =
Number of diagnostic procedures performed based on negative findings =
Total cost to system for diagnosis only =
Cost per patient for medical management [PT](10.6 sessions over 10 wks) =
Number FN patients who had insurance (@85% of FN) =
Total costs to system for medical mgmt of FN findings on MRI =
Percent of patients under medical mgmt crossing over to surgery(1)
Number of patients who crossed over ©) to surgery in FN group =
Cost of FN medical mgmt patients crossing over to surgery =
Number of patients who underwent phys ther post surgical arthroscopy (@85%) =
Costs for patients under physical therapy post surgery for TP, FP, and FN results =
SOC Cost
23,872
$934,776,977
263,311
$154,125,092
$1,318
23,872
$31,453,174
22%
5,252
$26,466,017
171,443
$225,888,971
$1,372,710,232
Notes
(FN)
(FN+TN)
(FN)
(FN)
(FN CO)
(TP+FP+FN CO)
(TP+FP+FN CO)
VSI Cost
0
$926,392,913
264,866
$155,627,316
$1,318
0
$0
0%
0
$0
164,636
$216,920,442
$1,298,940,671
Notes
(FP+TN)
(FN)
(FN)
(FN+TP)
(FN+TP)
Total costs positive and negative findings =
Sources:
(1) National Ambulatory Medical Care Survey data 2010 - based on 2010 figures for arthrocentesis of shoulder for rotator cuff lesion (35,000/970,000 = 8%)
(2) Brox JI, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease - prospective RCT with 2.5 year follow-up
Jour Should Elbow Surg;1999;8(2):102-11.
2
Complications for arthroscopy procedures
Arthrofibrosis [includes CPT 29825 and APC 0042]
Reoperation (any reason) [includes costs of CPT 29827 & APC 0042]
Venous thromboemblism (VTE) [includes 12 month for treatment]
Deep vein thrombosis (DVT) [includes 12 month for treatment]
Pulmonary embolism (PE) [includes 12 month for treatment]
Deep infection [includes DRG 863 - med treatment of post of infection]
Bicep tendon rupture
Number of arthroscopic procedures which complications were applied to =
Occurrence of complications based on incidence and number of procedures
Arthrofibrosis [includes CPT 29825 and APC 0042]
Reoperation (any reason) [includes costs of CPT 29827 & APC 0042]
Venous thromboemblism (VTE) [includes 12 month for treatment]
Deep vein thrombosis (DVT) [includes 12 month for treatment]
Pulmonary embolism (PE) [includes 12 month for treatment]
Deep infection [includes DRG 863 - med treatment of post of infection]
Bicep tendon rupture
Overall costs for complications
Incidence
1.00%
0.04%
0.38%
0.03%
0.02%
0.20%
0.20%
Arthrofibrosis [includes CPT 29825 and APC 0042]
Reoperation (any reason) [includes costs of CPT 29827 & APC 0042]
Venous thromboemblism (VTE) [includes 12 month for treatment]
Deep vein thrombosis (DVT) [includes 12 month for treatment]
Pulmonary embolism (PE) [includes 12 month for treatment]
Deep infection [includes DRG 863 - med treatment of post of infection]
Bicep tendon rupture
Total costs complications
Cost per patient complication
Total costs - diagnosis, therapeutics, and complications
Cost differential complications (which costs more and by how much) =
Overall cost per patient
Cost differential per patient (which costs more and by how much) =
3
Cost/event
$4,474.60
$4,966.57
$14,865.00
$14,865.00
$22,900.00
$5,665.00
$11,621.00
171,443
Incidence
0.64%
0.01%
0.24%
0.02%
0.01%
0.13%
0.13%
Cost/event
$4,474.60
$4,966.57
$14,865.00
$14,865.00
$22,900.00
$5,665.00
$11,621.00
429,501
1,714
65
651
50
29
343
343
2,743
43
1,042
80
47
549
549
$7,671381
$323,563
$9,684,292
$739,064
$667,427
$1,942,447
$3,984,674
$25,012,50
$145.90
$1,397,723,082
$59,073,555
$8,153
$345
$12,271,936
$213,315
$15,491,997
$1,182,284
$1,067,685
$3,107,340
$6,374,298
$39,708,855
$92.44
$1,338,649,527
$7,808
4