Pub Date : 2025-12-01DOI: 10.1016/j.scrs.2025.101133
Kelly M. Tyler M.D. (Guest Editor)
{"title":"Colorectal Billing, Coding, and Reimbursement: Understanding the Basics and Navigating Complexity","authors":"Kelly M. Tyler M.D. (Guest Editor)","doi":"10.1016/j.scrs.2025.101133","DOIUrl":"10.1016/j.scrs.2025.101133","url":null,"abstract":"","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 4","pages":"Article 101133"},"PeriodicalIF":0.5,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658891","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.scrs.2025.101137
Lynn M. O’Connor , Joshua A. Waters
The use of unlisted procedural codes in surgical billing poses risks of under-reimbursement or denial, especially in innovative fields like minimally invasive surgery. These codes are required when procedures lack specific CPT codes, often for new, experimental, or discontinued services. Proper documentation and preparation are crucial to secure reimbursement and reduce risks.
Unlisted codes should be compared to reference CPT codes to aid pricing and justification. Detailed documentation must include a description of the procedure, its complexity, necessity, and outcomes. This supports claims and ensures payer collaboration.
Reimbursement and RVU negotiations benefit from transparency regarding costs, resource demands, and historical data. Highlighting advanced technologies, specialized teams, or prolonged hospital stays can justify higher rates. For RVU-based models like Medicare, comparing complexity and resource use to reference codes is essential.
Preauthorization, appeals, and adherence to payer guidelines remain critical for success, ensuring fair compensation while reflecting the procedure’s true effort and value.
{"title":"Coding and reimbursement for unlisted anorectal and abdominal surgical procedures seminars in colon and rectal surgery","authors":"Lynn M. O’Connor , Joshua A. Waters","doi":"10.1016/j.scrs.2025.101137","DOIUrl":"10.1016/j.scrs.2025.101137","url":null,"abstract":"<div><div>The use of unlisted procedural codes in surgical billing poses risks of under-reimbursement or denial, especially in innovative fields like minimally invasive surgery. These codes are required when procedures lack specific CPT codes, often for new, experimental, or discontinued services. Proper documentation and preparation are crucial to secure reimbursement and reduce risks.</div><div>Unlisted codes should be compared to reference CPT codes to aid pricing and justification. Detailed documentation must include a description of the procedure, its complexity, necessity, and outcomes. This supports claims and ensures payer collaboration.</div><div>Reimbursement and RVU negotiations benefit from transparency regarding costs, resource demands, and historical data. Highlighting advanced technologies, specialized teams, or prolonged hospital stays can justify higher rates. For RVU-based models like Medicare, comparing complexity and resource use to reference codes is essential.</div><div>Preauthorization, appeals, and adherence to payer guidelines remain critical for success, ensuring fair compensation while reflecting the procedure’s true effort and value.</div></div>","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 4","pages":"Article 101137"},"PeriodicalIF":0.5,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658895","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.scrs.2025.101132
Kelly M. Tyler MD
{"title":"Corrigendum to “Advanced practice providers: An evolution of the scope of practice and clinical integration across the surgical healthcare landscape” [Seminars in Colon and Rectal Surgery Volume 35, issue 3 (2024) 101039]","authors":"Kelly M. Tyler MD","doi":"10.1016/j.scrs.2025.101132","DOIUrl":"10.1016/j.scrs.2025.101132","url":null,"abstract":"","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 4","pages":"Article 101132"},"PeriodicalIF":0.5,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658898","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.scrs.2025.101138
By Nicholas A. Davis , David E. Stein MD, MHCM
Physician compensation models have evolved significantly over the past decades, with Relative Value Units (RVUs) becoming a central benchmark for productivity and remuneration. This paper explores the origins of RVUs, their application in physician compensation, and the consequences of productivity-driven pay structures. While RVU-based compensation can standardize productivity measurements, it can also incentivize volume over quality, potentially leading to physician burnout and unnecessary procedures. Alternative models from leading healthcare organizations such as Mayo Clinic, Cleveland Clinic, Geisinger, and Intermountain Health demonstrate more balanced approaches that prioritize quality outcomes and physician satisfaction. Finally, we propose a structured framework for designing physician compensation models that integrate productivity with meaningful quality incentives. Through thoughtful implementation, healthcare systems can align physician compensation with both organizational goals and patient-centered care.
{"title":"Benchmarking physician productivity: The modern reality of physician compensation","authors":"By Nicholas A. Davis , David E. Stein MD, MHCM","doi":"10.1016/j.scrs.2025.101138","DOIUrl":"10.1016/j.scrs.2025.101138","url":null,"abstract":"<div><div>Physician compensation models have evolved significantly over the past decades, with Relative Value Units (RVUs) becoming a central benchmark for productivity and remuneration. This paper explores the origins of RVUs, their application in physician compensation, and the consequences of productivity-driven pay structures. While RVU-based compensation can standardize productivity measurements, it can also incentivize volume over quality, potentially leading to physician burnout and unnecessary procedures. Alternative models from leading healthcare organizations such as Mayo Clinic, Cleveland Clinic, Geisinger, and Intermountain Health demonstrate more balanced approaches that prioritize quality outcomes and physician satisfaction. Finally, we propose a structured framework for designing physician compensation models that integrate productivity with meaningful quality incentives. Through thoughtful implementation, healthcare systems can align physician compensation with both organizational goals and patient-centered care.</div></div>","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 4","pages":"Article 101138"},"PeriodicalIF":0.5,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658896","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.scrs.2025.101134
Eric G. Weiss , Brett P. Weiss
American healthcare policy requires a standard nomenclature(CPT) and valuation process(RUC). We review the makeup of both the CPT panel and advisory panel as well as the processes to create new CPT codes and edit current CPT codes as medical care and technology changes. We describe the RUC panel composition and the processes for determining the valuation of these new or edited CPT codes.
{"title":"The American medical association current procedural technology and relative value update committee process: How surgical work is defined and valued","authors":"Eric G. Weiss , Brett P. Weiss","doi":"10.1016/j.scrs.2025.101134","DOIUrl":"10.1016/j.scrs.2025.101134","url":null,"abstract":"<div><div>American healthcare policy requires a standard nomenclature(CPT) and valuation process(RUC). We review the makeup of both the CPT panel and advisory panel as well as the processes to create new CPT codes and edit current CPT codes as medical care and technology changes. We describe the RUC panel composition and the processes for determining the valuation of these new or edited CPT codes.</div></div>","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 4","pages":"Article 101134"},"PeriodicalIF":0.5,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658892","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.scrs.2025.101141
Scott E. Regenbogen MD, MPH
Surgeons are generally familiar with Current Procedural Terminology (CPT®) coding for office and operative care, but have less awareness of billing and risk-adjustment around hospitalization and overall costs of care. Hospitals use Diagnosis-Related Groups (DRGs) to designate indications for and complexity of inpatient care. Accountable Care Organizations (ACOs) receive global per capita according to algorithms defined by Hierarchical Condition Categories (HCCs) which estimate individuals’ costliness by defined disease states. An understanding of these coding systems and their uses will enable surgeons to properly document the complexity of care they provide patients within rapidly evolving reimbursement and quality assessment programs.
{"title":"Diagnosis related groups and hierarchical condition categories: what are they and why do they matter to surgeons?","authors":"Scott E. Regenbogen MD, MPH","doi":"10.1016/j.scrs.2025.101141","DOIUrl":"10.1016/j.scrs.2025.101141","url":null,"abstract":"<div><div>Surgeons are generally familiar with Current Procedural Terminology (CPT®) coding for office and operative care, but have less awareness of billing and risk-adjustment around hospitalization and overall costs of care. Hospitals use Diagnosis-Related Groups (DRGs) to designate indications for and complexity of inpatient care. Accountable Care Organizations (ACOs) receive global per capita according to algorithms defined by Hierarchical Condition Categories (HCCs) which estimate individuals’ costliness by defined disease states. An understanding of these coding systems and their uses will enable surgeons to properly document the complexity of care they provide patients within rapidly evolving reimbursement and quality assessment programs.</div></div>","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 4","pages":"Article 101141"},"PeriodicalIF":0.5,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658897","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.scrs.2025.101135
Daniel R. Fish, Kelly M. Tyler
The use of supplementary codes to adjust primary billing codes that describe surgical services are a source of potential deserved additional revenue. The American Medical Association (AMA) maintains the Current Procedural Technology (CPT®) set of codes which include “modifier” codes that are used in addition to primary procedure codes. The Centers for Medicare and Medicaid (CMS) maintains a set of G codes which are part of the Healthcare Common Procedural Coding System (HCPCS). Both sets of codes are complex, extensive and have requirements in appropriate use and documentation, but successful use can improve financial reflection of the full extent of the services provided in colorectal practice. This article explores both CPT® modifiers and G codes and provides the reader a summary of the most relevant codes along with their appropriate uses and tips for successful application in practice.
{"title":"Common procedural terminology code modifiers and G codes: Understanding their effect on reimbursement in colorectal surgical practice","authors":"Daniel R. Fish, Kelly M. Tyler","doi":"10.1016/j.scrs.2025.101135","DOIUrl":"10.1016/j.scrs.2025.101135","url":null,"abstract":"<div><div>The use of supplementary codes to adjust primary billing codes that describe surgical services are a source of potential deserved additional revenue. The American Medical Association (AMA) maintains the Current Procedural Technology (CPT®) set of codes which include “modifier” codes that are used in addition to primary procedure codes. The Centers for Medicare and Medicaid (CMS) maintains a set of G codes which are part of the Healthcare Common Procedural Coding System (HCPCS). Both sets of codes are complex, extensive and have requirements in appropriate use and documentation, but successful use can improve financial reflection of the full extent of the services provided in colorectal practice. This article explores both CPT® modifiers and G codes and provides the reader a summary of the most relevant codes along with their appropriate uses and tips for successful application in practice.</div></div>","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 4","pages":"Article 101135"},"PeriodicalIF":0.5,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658893","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.scrs.2025.101136
Brendan Scully, Daniel Feingold
Colon and rectal surgery is commonly performed by both general and colon and rectal surgeons. Guidelines around proper coding and reimbursing can be complicated and difficult to interpret for both surgeons and their coders. The goal of this paper is to review common Current Procedural Terminology (CPT) codes and the proper use of modifiers as they relate to complex open colorectal surgery and multi-disciplinary procedures to facilitate accurate coding.
{"title":"Coding complex open colorectal abdominal operations","authors":"Brendan Scully, Daniel Feingold","doi":"10.1016/j.scrs.2025.101136","DOIUrl":"10.1016/j.scrs.2025.101136","url":null,"abstract":"<div><div>Colon and rectal surgery is commonly performed by both general and colon and rectal surgeons. Guidelines around proper coding and reimbursing can be complicated and difficult to interpret for both surgeons and their coders. The goal of this paper is to review common Current Procedural Terminology (CPT) codes and the proper use of modifiers as they relate to complex open colorectal surgery and multi-disciplinary procedures to facilitate accurate coding.</div></div>","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 4","pages":"Article 101136"},"PeriodicalIF":0.5,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145658894","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-23DOI: 10.1016/j.scrs.2025.101122
Yasamin Taghikhan MD, Sean Flynn MD
The incidence of colorectal cancer (CRC) in individuals under 50 years of age—termed young-onset colorectal cancer (YOCRC)—has been increasing despite declining rates of CRC overall. YOCRC now comprises up to 15 % of new CRC diagnoses. Most cases of YOCRC are sporadic, occurring without identifiable hereditary syndromes or family history. It exhibits distinct epidemiological and molecular characteristics, including a predilection for rectal and left-sided tumors, aggressive histology, and more advanced stage at diagnosis. Suspected risk factors contributing to this rising incidence are multifactorial and include lifestyle and environmental exposures, such as westernized diets, obesity, sedentary behavior, increased antibiotic exposure, and chronic inflammation. These factors interact with the gut microbiome to induce dysbiosis, pro-inflammatory states, and DNA damage. At the molecular level, YOCRC is most associated with chromosomal instability (CIN), while a minority exhibit microsatellite instability (MSI) or CpG island methylator phenotype (CIMP). Compared to late-onset CRC, YOCRC displays lower rates of KRAS, BRAF, and APC mutations, but increased TP53 and PTEN alterations. Emerging research also highlights differences in the tumor microenvironment, including immune cell infiltration and complement expression, which may influence therapeutic response. Understanding the unique biology of sporadic YOCRC is essential for developing risk stratification models, refining screening strategies, and advancing targeted treatment approaches. Continued investigation into genetic susceptibility, environmental triggers, and tumor immunobiology will be crucial in addressing this evolving public health challenge.
{"title":"Epidemiology, molecular biology, and genetics of sporadic young onset colorectal cancer","authors":"Yasamin Taghikhan MD, Sean Flynn MD","doi":"10.1016/j.scrs.2025.101122","DOIUrl":"10.1016/j.scrs.2025.101122","url":null,"abstract":"<div><div>The incidence of colorectal cancer (CRC) in individuals under 50 years of age—termed young-onset colorectal cancer (YOCRC)—has been increasing despite declining rates of CRC overall. YOCRC now comprises up to 15 % of new CRC diagnoses. Most cases of YOCRC are sporadic, occurring without identifiable hereditary syndromes or family history. It exhibits distinct epidemiological and molecular characteristics, including a predilection for rectal and left-sided tumors, aggressive histology, and more advanced stage at diagnosis. Suspected risk factors contributing to this rising incidence are multifactorial and include lifestyle and environmental exposures, such as westernized diets, obesity, sedentary behavior, increased antibiotic exposure, and chronic inflammation. These factors interact with the gut microbiome to induce dysbiosis, pro-inflammatory states, and DNA damage. At the molecular level, YOCRC is most associated with chromosomal instability (CIN), while a minority exhibit microsatellite instability (MSI) or CpG island methylator phenotype (CIMP). Compared to late-onset CRC, YOCRC displays lower rates of KRAS, BRAF, and APC mutations, but increased TP53 and PTEN alterations. Emerging research also highlights differences in the tumor microenvironment, including immune cell infiltration and complement expression, which may influence therapeutic response. Understanding the unique biology of sporadic YOCRC is essential for developing risk stratification models, refining screening strategies, and advancing targeted treatment approaches. Continued investigation into genetic susceptibility, environmental triggers, and tumor immunobiology will be crucial in addressing this evolving public health challenge.</div></div>","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 3","pages":"Article 101122"},"PeriodicalIF":0.5,"publicationDate":"2025-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144828435","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-07-22DOI: 10.1016/j.scrs.2025.101121
Thomas A. Sorrentino , B. Mark Zhao
Colorectal cancer (CRC) is a leading cause of cancer-related deaths globally, with rising concerns about its increased incidence in individuals under 50, termed young-onset CRC. Despite declines in CRC rates overall, young-onset CRC has risen by 1–3 % annually in the US and Europe. This rise is most pronounced in rectal cancer and is projected to result in significant growth in CRC cases among individuals aged 20–49 over the next decade. While most young-onset CRCs are sporadic, approximately 15 % of cases are linked to genetic syndromes. This review explores the genetic syndromes associated with young-onset CRC, distinguishing between polyposis and non-polyposis types, and discusses diagnostic strategies, management, and multidisciplinary care approaches essential for colorectal surgeons treating these patients.
{"title":"Young onset colorectal cancer in hereditary syndromes","authors":"Thomas A. Sorrentino , B. Mark Zhao","doi":"10.1016/j.scrs.2025.101121","DOIUrl":"10.1016/j.scrs.2025.101121","url":null,"abstract":"<div><div>Colorectal cancer (CRC) is a leading cause of cancer-related deaths globally, with rising concerns about its increased incidence in individuals under 50, termed young-onset CRC. Despite declines in CRC rates overall, young-onset CRC has risen by 1–3 % annually in the US and Europe. This rise is most pronounced in rectal cancer and is projected to result in significant growth in CRC cases among individuals aged 20–49 over the next decade. While most young-onset CRCs are sporadic, approximately 15 % of cases are linked to genetic syndromes. This review explores the genetic syndromes associated with young-onset CRC, distinguishing between polyposis and non-polyposis types, and discusses diagnostic strategies, management, and multidisciplinary care approaches essential for colorectal surgeons treating these patients.</div></div>","PeriodicalId":55956,"journal":{"name":"Seminars in Colon and Rectal Surgery","volume":"36 3","pages":"Article 101121"},"PeriodicalIF":0.5,"publicationDate":"2025-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144828434","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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