JBJS | Cost and Effectiveness of Routine Pathological Examination of Operative Specimens Obtained During Primary Total Hip and Knee Replacement in Patients with Osteoarthritis*

The Journal of Bone & Joint Surgery, Volume 82, Issue 11

Articles | November 01, 2000

Cost and Effectiveness of Routine Pathological Examination of Operative Specimens Obtained During Primary Total Hip and Knee Replacement in Patients with Osteoarthritis*

Mininder S. Kocher, M.D.M.P.H.†; Greg Erens, M.D.‡; Thomas S. Thornhill, M.D.‡; John E. Ready, M.D.‡

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Investigation performed at the Department of Orthopaedic Surgery, Brigham and Women's Hospital, and the Harvard School of Public Health, Boston, Massachusetts
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was an American Academy of Orthopaedic Surgeons/Orthopaedic Research and Education Foundation Health Services Research Fellowship Grant (M. S. K.).
†Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115. E-mail address: kocher_m@a1.tch.harvard.edu.
‡Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115.

The Journal of Bone & Joint Surgery. 2000; 82:1531-1531

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Abstract

Background: The challenge of cost-efficiency is maintaining the quality of medical care while reducing costs and eliminating unnecessary practices. The purpose of this investigation was to evaluate the cost and effectiveness of routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement for the treatment of osteoarthritis.

Methods: Effectiveness was assessed by comparing clinical and pathological diagnoses associated with 1234 consecutive primary total joint replacements (471 hip and 763 knee replacements) performed between 1992 and 1995 in one hospital in patients with the clinical diagnosis of osteoarthritis. Clinical and pathological diagnoses were considered concordant if they agreed, discrepant if they differed without a resultant change in patient management, and discordant if they differed with a resultant change in patient management. Cost identification was performed by determining charges, reimbursement, and costs in 1998-adjusted American dollars for both total hip and total knee replacement. The cost per health-effect was determined by calculating the cost per discrepant and discordant diagnosis.

Results: The prevalence of concordant diagnoses was 97.6 percent (1205 of 1234) (95 percent confidence interval, 96.6 to 98.4 percent), the prevalence of discrepant diagnoses was 2.3 percent (twenty-eight of 1234) (95 percent confidence interval, 1.4 to 3.1 percent), and the prevalence of discordant diagnoses was 0.1 percent (one of 1234) (95 percent confidence interval, 0.1 to 0.3 percent). The cost per discrepant diagnosis was $4383, and the cost per discordant diagnosis was $122,728.

Conclusions: Routine pathological examination of surgical specimens from patients undergoing primary total hip or knee replacement because of the clinical diagnosis of osteoarthritis had limited cost-effectiveness at our hospital due to the low prevalence of findings that altered patient management.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The challenge of cost-efficiency is maintaining the quality of medical care while reducing costs and eliminating unnecessary practices. To this end, the utility of many aspects of total joint replacement have been reexamined.

It is routine practice at most hospitals to submit tissue removed at the time of total joint arthroplasty to a pathology laboratory for evaluation. According to standards recommended by the Joint Commission on Accreditation of Healthcare Organizations, the professional staff of a hospital may identify types of specimens that may be discarded in the operating room and are submitted to the pathology department only at the discretion of the surgeon¹¹. This decision usually results from cooperation among surgeons, pathologists, and a "quality-care" or "tissue" committee, and it is made with the assumption that the quality of patient care is not compromised by the exception. The utility of routine pathological examination of surgical specimens such as intervertebral discs³, hernia sacs^13,24, tonsils and adenoid tissue¹⁸, gallbladders²⁴, and appendices²⁴ has been reassessed recently given the low yield of important findings that alter patient management.

The purpose of this study was to evaluate the effectiveness and to identify the costs of routine pathological examination of operative specimens obtained during primary total knee and hip replacement performed for the treatment of osteoarthritis.

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Table I: Reimbursement Calculation

*1998 American dollars.†Weighted mean.

	Total Hip Replacement*	Total Knee Replacement*
Medicare	Other Payers†	Medicare	Other Payers†
CPT 88304/5 (specimen)
Part A	$15.45	$35.05	$23.28	$45.11
Part B	$17.47	$24.77	$49.20	$53.82
CPT 88311 (decalcification)
Part A	$4.57	$10.04	$4.57	$10.04
Part B	$13.69	$15.13	$3.69	$15.13
Total per case	$51.18	$84.99	$80.74	$124.10

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Table I: Reimbursement Calculation

*1998 American dollars.†Weighted mean.

	Total Hip Replacement*	Total Knee Replacement*
Medicare	Other Payers†	Medicare	Other Payers†
CPT 88304/5 (specimen)
Part A	$15.45	$35.05	$23.28	$45.11
Part B	$17.47	$24.77	$49.20	$53.82
CPT 88311 (decalcification)
Part A	$4.57	$10.04	$4.57	$10.04
Part B	$13.69	$15.13	$3.69	$15.13
Total per case	$51.18	$84.99	$80.74	$124.10

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Table II: Cost Calculation

*1998 American dollars.

	Total Hip Replacement	Total Knee Replacement
Part A (technical)
Cost per block*	$19.92	$20.67
Blocks per case	2.1	2.4
Cost per case*	$41.83	$49.61
Part B (professional)
Cost per minute*	$2.25	$2.25
Minutes per slide	10	10
Slides per case	2.1	2.5
Cost per case*	$47.25	$56.25
Total per case*	$89.08	$105.86

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Table II: Cost Calculation

*1998 American dollars.

	Total Hip Replacement	Total Knee Replacement
Part A (technical)
Cost per block*	$19.92	$20.67
Blocks per case	2.1	2.4
Cost per case*	$41.83	$49.61
Part B (professional)
Cost per minute*	$2.25	$2.25
Minutes per slide	10	10
Slides per case	2.1	2.5
Cost per case*	$47.25	$56.25
Total per case*	$89.08	$105.86

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Table III: Charges, Reimbursement, and Cost per Case

*1998 American dollars.

	Total Hip Replacement*	Total Knee Replacement*
Charges	$233.00	$304.00
Reimbursement
Medicare	$51.18	$80.74
Other payers	$84.99	$124.10
Cost	$89.08	$105.86

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Table III: Charges, Reimbursement, and Cost per Case

*1998 American dollars.

	Total Hip Replacement*	Total Knee Replacement*
Charges	$233.00	$304.00
Reimbursement
Medicare	$51.18	$80.74
Other payers	$84.99	$124.10
Cost	$89.08	$105.86

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Effectiveness

We performed a retrospective review that included 1234 consecutive primary total hip replacements and primary total knee replacements performed in one hospital between 1992 and 1995 for patients with the preoperative clinical diagnosis of osteoarthritis. Four hundred and seventy-one total hip replacements were done in 452 patients, who had a mean age of 67.7 years (range, forty-one to eighty-seven years); 56 percent were female. Seven hundred and sixty-three total knee replacements were done in 602 patients, who had a mean age of 69.3 years (range, forty-four to eighty-eight years); 65 percent were female.

The preoperative clinical diagnosis was determined for all patients on the basis of the history, physical examination, and radiographs. The operative diagnosis was determined on the basis of intraoperative findings and did not differ from the preoperative clinical diagnosis in any case. The pathological diagnosis was determined for all patients by gross and histological examination of the surgical specimens. All tissue specimens were evaluated systematically according to the guidelines of the College of American Pathologists⁶. Bone, soft tissue, and cartilaginous joint surfaces were examined grossly for any remarkable external features. Sagittal slices were cut from the joint tissue for gross examination of the subchondral bone and medullary component. Sections containing joint surface, subchondral bone, and medullary cavity were fixed in 10 percent buffered formalin and decalcified. Soft-tissue specimens were not decalcified. After routine processing, specimens were stained with hematoxylin and eosin and examined histologically.

Patients with discrepancies between the preoperative clinical diagnosis and the pathological diagnosis were followed with use of medical records and telephone contact to determine their clinical course. Twenty-nine patients were followed in this manner at a mean of 4.2 years (range, 2.1 to 5.2 years) after the index operative procedure. Patients with concordance between the preoperative clinical diagnosis and the pathological diagnosis were not followed. Diagnoses were considered concordant if there was agreement between the clinical diagnosis and the pathological diagnosis. Diagnoses were classified as discrepant if they differed without a resultant change in patient management and as discordant if they differed with a resultant change in patient management. The rates of concordant, discrepant, and discordant diagnoses were reported, with 95 percent confidence intervals determined with use of the standard formula for normal approximations (SAS, version 6.12; SAS Institute, Cary, North Carolina).

Cost Identification

The cost of routine pathological examination of surgical specimens was identified by determining charges, reimbursement, and costs in 1998-adjusted American dollars for both total hip and total knee replacement.

Charges - both Part-A (technical) charges and Part-B (professional) charges - were obtained from the hospital billing office. Charges were reported as a per-case weighted mean and as a total sum over the study period for both total hip and total knee replacement.

Reimbursement for both Part-A (technical) and Part-B (professional) charges was dependent on CPT codes and the payer. For pathological examination of specimens obtained during total hip replacement, the CPT codes were 88304 (specimen code) and 88311 (decalcification code) and the payer mix was Medicare for 74 percent (349 of 471) and other insurance for 26 percent (122 of 471). For pathological examination of specimens obtained during total knee replacement, the CPT codes were 88305 (specimen code) and 88311 (decalcification code) and the payer mix was Medicare for 66 percent (504 of 763) and other insurance for 34 percent (259 of 763). Reimbursement was determined for each individual payer through the hospital accounting office and reported as a per-case weighted mean and as a total sum over the study period for both total hip and total knee replacement.

Part-A (technical) costs were determined on a per-block basis, and Part-B (professional) costs were determined on a per-slide basis. For Part A, costs per block were estimated by the pathology department auditor and financial manager with use of direct costs of material utilization and technician time based on ten representative cases. Indirect costs were not included. The mean number of blocks per case was determined from pathology worksheets. For Part B, costs per minute of analysis by the pathologist were estimated by the pathology department auditor and financial manager based on ten representative cases with use of direct costs of the pathologist's time, including salary and benefits. Again, indirect costs were not included. The mean number of slides per case was determined from pathology worksheets, and the mean amount of time per slide was determined from an internal pathology department audit. Costs were reported as a per-case mean and as a total sum over the study period for both total hip and total knee replacement. Costs were also reported per discrepant diagnosis and per discordant diagnosis.

Results

Introduction | Materials and Methods | Results | Discussion | References

Effectiveness

The prevalence of concordant diagnoses was 97.6 percent (1205 of 1234) (95 percent confidence interval, 96.6 to 98.4 percent), the prevalence of discrepant diagnoses was 2.3 percent (twenty-eight of 1234) (95 percent confidence interval, 1.4 to 3.1 percent), and the prevalence of discordant diagnoses was 0.1 percent (one of 1234) (95 percent confidence interval, 0.1 to 0.3 percent). Discrepant pathological diagnoses included eight diagnoses of rheumatoid arthritis (three total knee replacements and five total hip replacements), six diagnoses of osteonecrosis (all total hip replacements), four diagnoses of pseudogout (all total knee replacements), four diagnoses of pigmented villonodular synovitis (three total knee replacements and one total hip replacement), three diagnoses of hemochromatosis (all total knee replacements), two diagnoses of hypercellular marrow (one total knee replacement and one total hip replacement), and one diagnosis of gout (a total hip replacement). Follow-up revealed no change in the management of the patients with a discrepant pathological diagnosis. Review of the medical records and telephone contact revealed that these patients had had no formal diagnosis or clinical symptoms of these conditions prior to or since the total joint replacement. The two patients with a pathological diagnosis of hypercellular marrow had not had a diagnosis of a lymphoproliferative or neoplastic disease prior to or since total joint replacement; however, a formal hematological work-up had not been performed. The three patients with a pathological diagnosis of hemochromatosis had negative findings for hepatosplenomegaly on physical examination and on laboratory evaluation of serum iron level, iron-binding capacity, and ferritin and transferrin levels.

The one discordant pathological diagnosis was of granulomatous inflammation. The patient had no clinical diagnosis of a granulomatous disease, such as tuberculosis or sarcoidosis, prior to total joint replacement. The change in patient management resulting from the pathological diagnosis involved continued medical follow-up for potential systemic granulomatous disease.

Cost Identification

In 1998-adjusted American dollars, the mean reimbursement per case for pathological examination during total hip replacement was $51.18 for patients receiving Medicare and $84.99 for patients insured by other payers (Table I). The mean reimbursement per case for pathological examination during total knee replacement was $80.74 for patients receiving Medicare and $124.10 for patients insured by other payers (Table I). The mean cost per case was $89.08 for total hip replacement and $105.86 for total knee replacement (Table II). The mean charge per case was $233.00 for total hip replacement and $304.00 for total knee replacement (Table III). The total charge for pathological examination of operative specimens over the study period was $341,695, the total reimbursement was $106,105, and the total cost was $122,728.

The cost per discrepant diagnosis was found to be $4383 ($122,728 total cost divided by twenty-eight discrepant diagnoses). The cost per discordant diagnosis was $122,728 ($122,728 total cost divided by one discordant diagnosis).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

In this study, we identified the costs and questioned the effectiveness of routine pathological examination of surgical specimens obtained during primary total hip and knee replacement for the treatment of osteoarthritis. The traditional goals of pathological examination of surgical specimens are to provide diagnostic information to guide patient care, to allow a means of diagnostic quality assurance, to document the tissue that was removed, and to gain insight into the pathoetiology of the disease^4,18,24. The primary clinical utility of routine pathological examination lies in the potential effect of discordant pathological diagnoses on patient management and the information with regard to the quality of clinical diagnoses provided by discrepant pathological diagnoses. In this large consecutive series of primary total hip and knee replacements in patients with the clinical diagnosis of osteoarthritis, routine pathological examination had minimal effect on patient management. From a quality-assurance viewpoint, routine pathological examination did reveal discrepant diagnoses; however, the prevalence was low (2.3 percent) and the costs were high ($4383 per discrepant diagnosis).

Other studies evaluating the utility of routine pathological examination of surgical specimens obtained during total joint replacement have demonstrated similar findings. In six series ranging from 168 to 2289 total hip or knee arthroplasties for all indications, rates of discrepant diagnoses were 0.8 to 8.9 percent^{5,14-16,20,23}. In these series, which included a total of 7154 arthroplasties, there was only one reported discordant diagnosis; this was a pathological diagnosis that was found, on reexamination of the pathological specimen, to conflict with the original pathological diagnosis²³.

Nevertheless, there have been reports of important morbid conditions detected by routine pathological examination of surgical specimens obtained during total joint replacement. Bessner reported a case of unsuspected tuberculosis detected by routine pathological examination of synovial tissue obtained during a total knee replacement². Kahn and Blazina reported a case of metastatic mammary carcinoma that was detected incidentally on routine histological examination of a specimen taken during a total knee replacement in a seventy-year-old woman¹². In retrospect, however, it was realized that the patient had had findings of breast carcinoma with axillary node involvement on physical examination. An abstract by DiCarlo et al. presented the results of pathological examination of 1794 femoral head surgical specimens obtained during a twelve-month period, apparently for all indications, including fracture⁸. Overall, there was disagreement between the clinical and pathological diagnoses in 5.4 percent of the cases, including five in which an important morbid condition was detected incidentally on pathological evaluation; these conditions included myeloma, sarcoma, ochronosis, Gaucher disease, and Paget disease. Disagreement between the clinical and histological findings was more common for certain diagnoses. Only 67 percent (ninety-four) of the 140 cases of osteonecrosis and 90 percent (sixty-nine) of the seventy-seven cases of inflammatory arthritis that were detected histologically were diagnosed clinically.

Economic analysis of medical procedures includes cost-identification studies, which determine costs, and cost-evaluation studies, which assess both costs and benefits. Cost-evaluation study designs include cost-benefit, cost-effectiveness, and cost-utility analyses^7,9. In the present study, we assessed the effectiveness of routine pathological examination by determining the prevalence of discordant diagnoses (those that altered patient management) and discrepant diagnoses, which may allow for quality assurance of clinical diagnosis. We identified the charges, reimbursement, and costs of routine pathological examination of specimens obtained during total hip and knee replacement. Cost is the most stable and relevant economic parameter because charges and reimbursement are more subjective and may vary widely by payer and geographic region. Because our cost calculation included only direct costs, such as those for materials and personnel, the actual costs may have been even higher as a result of indirect costs, such as those for capital expenses, laboratory space, training, and utilities. Interestingly, except for the cost of pathological analysis of knee replacement specimens reimbursed by non-Medicare payers, the cost of pathological examination exceeded reimbursement. In determining costs per health-effect, we found that the cost per discrepant diagnosis was more than $4000 and the cost per discordant diagnosis was more than $100,000. In a cost-utility analysis of routine pathological examination of surgical specimens, which would quantify the cost per quality-adjusted life-year, contributing factors would include the incidence of discordant diagnoses, the cost of pathological examination, the gain in life expectancy or quality of life resulting from discordant diagnoses, and the valuation of a quality-adjusted life-year^19,21-23.

Netser et al. proposed a value-based pathology system in which the utility of specimen examination must justify the cost¹⁸. Using this method of analysis, these researchers concluded that pathological examination of nonroutine tonsil and adenoid specimens appeared justified, whereas examination of routine specimens did not. Similarly, the utility of routine pathological examination of specimens such as intervertebral discs³, hernia sacs^13,24, gallbladders²⁴, and appendices²⁴ has been questioned, given the low yield of important findings that alter patient management. The results of our study and others^{5,14-16,20,23} suggest that, at least for patients with the preoperative clinical diagnosis of osteoarthritis, routine pathological examination of surgical specimens obtained during primary total hip and knee replacement may not be justified since the prevalence of findings that alter patient management is so low. Routine pathological examination may be justified for patients with other preoperative clinical diagnoses, such as osteonecrosis or inflammatory arthritis, since the prevalence of findings that alter patient management appears to be higher^1,8. The potential cost-savings from cessation of routine pathological examination of surgical specimens obtained during primary total hip and knee replacement for patients with the clinical diagnosis of osteoarthritis is substantial^10,17. In addition, the cost of pathological examination exceeded reimbursement in most instances, at least at our hospital. Many surgeons believe that routine pathological examination of surgical specimens is mandatory, and most hospital guidelines stipulate it. The regulations promulgated by the Joint Commission on Accreditation of Healthcare Organizations state that exceptions to mandatory submission of surgical specimens may be made by the clinical staff, in consultation with the pathologist, when three conditions are met: (1) the quality of care has not been compromised by the exception, (2) another suitable means of verification of the removal has been routinely used, and (3) there is an authenticated operative or other official report that documents the removal¹¹. Our study and others suggest that, at least for patients with the clinical diagnosis of osteoarthritis, the quality of care would not be compromised by the abandonment of the practice of routine submission of surgical specimens during total joint replacement since discrepant diagnoses are infrequent and discordant diagnoses are rare^{5,14-16,20,23}.

References

Introduction | Materials and Methods | Results | Discussion | References

Barrie, H. J.: Pathology of femoral heads in patients with rheumatoid disease. J. Rheumatol.,17: 448-459, 1990.17448 1990 [PubMed]

Bessner, M. I.: Total knee replacement in unsuspected tuberculosis of the joint. British Med. J.,280: 1434, 1980.2801434 1980

Boutin, P., and Hogshead, H.: Surgical pathology of the intervertebral disc. Is routine examination necessary?. Spine,17: 1236-1238, 1992.171236 1992 [PubMed]

Bullough, P. G., and Dorfman, H. D.: Editorial. The principle of utility in cost-based contemporary medical care. J. Bone and Joint Surg.,80-A: 311-312, March 1998.80-A311 1998

Campbell, M. L.; Gregory, A. M.; and Mauerhan, D. R.: Collection of surgical specimens in total joint arthroplasty. Is routine pathology cost effective?. J. Arthroplasty,12: 60-63, 1997.1260 1997 [PubMed]

College of American Pathologists: Laboratory Accreditation Program Manual. Northfield, Illinois, College of American Pathologists, 1999.

Detsky, A. S., and Naglie, I. G.: A clinician's guide to cost-effectiveness analysis. Ann. Intern. Med.,,113: 147-154, 1990.113147 1990

DiCarlo, E. F.; Bullough, P. G.; Steiner, G.; Bansal, M.; and Kambolis, C.: Pathological examination of the femoral head [abstract]. Mod. Pathol.,7: 6A, 1994.76 1994

Donaldson, C., and Shackley, P.: Economic evaluation. In Oxford Textbook of Public Health, pp. 849-871. Edited by R. Detels, W. W. Holland, J. McEwen, and G. S. Omenn. Oxford, Oxford University Press, 1997

Healy, W. L., and Finn, D.: The hospital cost and the cost of the implant for total knee arthroplasty: a comparison between 1983 and 1991 for one hospital. J. Bone and Joint Surg.,,76-A: 801-806, June 1994.76-A801 1994

Joint Commission on Accreditation of Healthcare Organizations: Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services. Oakbrook Terrace, Illinois, Joint Commission on Accreditation of Healthcare Organizations, 1996

Kahn, D. G., and Blazina, M. E.: Incidental metastatic mammary carcinoma in a total knee arthroplasty patient. Clin. Orthop.,295: 142-145, 1993.295142 1993 [PubMed]

Kassan, M. A.; Munoz, E.; Laughlin, A.; Margolis, I. B.; and Wise, L.: Value of routine pathology in herniorrhaphy performed upon adults. Surg., Gynec. and Obstet.,163: 518-522, 1986.163518 1986

Landon, G. C.; Lake, K.; and Fernau, R. C.: The value of routine pathologic examination of tissue from patients undergoing total hip and knee replacement. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons, Anaheim, California, Feb. 6, 1999.

Lawrence, T.; Moskal, J. T.; and Diduch, D. R.: Analysis of routine histological evaluation of tissues removed during primary hip and knee arthroplasty. J. Bone and Joint Surg.,81-A: 926-931, July 1999.81-A926 1999

Meding, J. B.; Ritter, M. A.; Jones, N. L.; Keating, E. M.; and Faris, P. M.: Determining the necessity for routine pathologic examinations in uncomplicated total hip and total knee arthroplasties. J. Arthroplasty,,15: 69-71, 2000.1569 2000

National Center for Health Statistics: National Hospital Discharge Survey: Annual Summary, 1993. Atlanta, United States Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, 1993

Netser, J. C.; Robinson, R. A.; Smith, R. J.;, and Raab, S. S.: Value-based pathology: a cost-benefit analysis of the examination of routine and nonroutine tonsil and adenoid specimens.. Am. J. Clin. Pathol.,108: 158-165, 1997.108158 1997 [PubMed]

Owens, D. K.; Sanders, G. D.; Harris, R. A.; McDonald, K. M.; Heidenreich, P. A.; Dembitzer, A. D.; and Hlatky, M. A.: Cost-effectiveness of implantable cardioverter defibrillators relative to amiodarone for prevention of sudden cardiac death. Ann. Intern. Med.,126: 1-12, 1997.1261 1997 [PubMed]

Pagnano, M. W.; Forero, J. H.; Scuderi, G. R.; and Harwin, S. F.: Is the routine examination of surgical specimens worthwhile in primary total knee arthroplasty?. Clin. Orthop.,356: 79-84, 1998.35679 1998 [PubMed]

Raab, S. S., and Hornberger, J.: The effect of a patient's risk-taking attitude on the cost effectiveness of testing strategies in the evaluation of pulmonary lesions. Chest,111: 1583-1590, 1997.1111583 1997 [PubMed]

Raab, S. S.: The cost-effectiveness of routine histologic examination. Am. J. Clin. Pathol.,110: 391-396, 1998.110391 1998 [PubMed]

Raab, S. S.; Slagel, D. D.; and Robinson, R. A.: The utility of histological examination of tissue removed during elective joint replacement: a preliminary assessment. J. Bone and Joint Surg.,80-A: 331-335, March 1998.80-A331 1998

Wolkomir, A. F.; Barone, J. E.; and Moser, R. L.: Selective microscopic examination of gallbladders, hernia sacs, and appendices. Am. Surgeon,57: 289-292, 1991.57289 1991 [PubMed]

Topics

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Table I: Reimbursement Calculation

*1998 American dollars.†Weighted mean.

	Total Hip Replacement*	Total Knee Replacement*
Medicare	Other Payers†	Medicare	Other Payers†
CPT 88304/5 (specimen)
Part A	$15.45	$35.05	$23.28	$45.11
Part B	$17.47	$24.77	$49.20	$53.82
CPT 88311 (decalcification)
Part A	$4.57	$10.04	$4.57	$10.04
Part B	$13.69	$15.13	$3.69	$15.13
Total per case	$51.18	$84.99	$80.74	$124.10

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Table I: Reimbursement Calculation

*1998 American dollars.†Weighted mean.

	Total Hip Replacement*	Total Knee Replacement*
Medicare	Other Payers†	Medicare	Other Payers†
CPT 88304/5 (specimen)
Part A	$15.45	$35.05	$23.28	$45.11
Part B	$17.47	$24.77	$49.20	$53.82
CPT 88311 (decalcification)
Part A	$4.57	$10.04	$4.57	$10.04
Part B	$13.69	$15.13	$3.69	$15.13
Total per case	$51.18	$84.99	$80.74	$124.10

View Larger

Table II: Cost Calculation

*1998 American dollars.

	Total Hip Replacement	Total Knee Replacement
Part A (technical)
Cost per block*	$19.92	$20.67
Blocks per case	2.1	2.4
Cost per case*	$41.83	$49.61
Part B (professional)
Cost per minute*	$2.25	$2.25
Minutes per slide	10	10
Slides per case	2.1	2.5
Cost per case*	$47.25	$56.25
Total per case*	$89.08	$105.86

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Table II: Cost Calculation

*1998 American dollars.

	Total Hip Replacement	Total Knee Replacement
Part A (technical)
Cost per block*	$19.92	$20.67
Blocks per case	2.1	2.4
Cost per case*	$41.83	$49.61
Part B (professional)
Cost per minute*	$2.25	$2.25
Minutes per slide	10	10
Slides per case	2.1	2.5
Cost per case*	$47.25	$56.25
Total per case*	$89.08	$105.86

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Table III: Charges, Reimbursement, and Cost per Case

*1998 American dollars.

	Total Hip Replacement*	Total Knee Replacement*
Charges	$233.00	$304.00
Reimbursement
Medicare	$51.18	$80.74
Other payers	$84.99	$124.10
Cost	$89.08	$105.86

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Table III: Charges, Reimbursement, and Cost per Case

*1998 American dollars.

	Total Hip Replacement*	Total Knee Replacement*
Charges	$233.00	$304.00
Reimbursement
Medicare	$51.18	$80.74
Other payers	$84.99	$124.10
Cost	$89.08	$105.86