Rationale and Objectives
Physicians from many specialties perform musculoskeletal biopsy. Using the Medicare database, we sought to determine which specialties represent the physicians who are performing the majority.
Materials and Methods
Using the CMS physician supplier procedure summary master file for 1996–2003, we extracted all claims for biopsy procedure codes (including marrow aspiration, muscle biopsy, percutaneous bone biopsy, and open surgical biopsy) categorized by provider specialty, and we analyzed procedure volumes.
Results
Since 1996, the rate of utilization of percutaneous bone biopsy has remained stable. In 2003, marrow aspiration was most commonly performed by hematology/oncology (80,038, 57%), followed by medical oncology (23,428, 17%); radiologists performed 755 (0.5%). Muscle biopsies were predominantly performed by radiologists (4,761, 40%), followed by neurosurgery (591, 5%). Percutaneous bone biopsy was mostly performed by radiologists (14,830, 53%), but orthopedic surgeons, neurosurgeons, and hematology/oncology specialists performed a large minority (6,879, 2,296, and 1,048 respectively; in aggregate, 37%). From 1996 to 2003, radiologists performed 71% more muscle biopsies (2,788 to 4,761) and 60% more percutaneous bone biopsies (9,259 to 14,830). Although most specialties are performing fewer percutaneous bone biopsies (e.g., oncologists: 7,217 to 1,048, −85%), orthopedic surgeons are performing 247% more (1,983 to 6,879) and neurosurgeons are performing 2,343% more (94 to 2,296).
Conclusion
Excluding marrow aspiration, radiologists perform the majority of percutaneous bone biopsies, and the volume is increasing in the U.S. Medicare population. The overall volume has remained relatively stable from 1996 to 2003; although medical specialties are performing fewer, the volume performed by surgeons is increasing rapidly.
Musculoskeletal biopsy is frequently performed to assess bone marrow pathology and to diagnose bone and soft tissue tumors, and it is also commonly used for the evaluation of suspected musculoskeletal infection. Correct diagnosis using the safest and most minimally invasive technique is what most clinicians hope to achieve when referring patients for musculoskeletal biopsy. The most suitable type of biopsy procedure for musculoskeletal lesions has been controversial ( ). Open surgical biopsy has the advantage that a large amount of the specimen can be sampled. Open biopsy can be associated with complications such as hematoma, infection, and tumor dissemination into the surgical bed. When compared to open biopsy percutaneous, musculoskeletal biopsy is associated with fewer complications ( ) and is more cost effective ( ). A variety of image guidance techniques are used to perform musculoskeletal biopsy, including fluoroscopy, ultrasound, computed tomography, and magnetic resonance imaging ( ). Some biopsy procedures are routinely performed by nonradiologists without image guidance (e.g., marrow aspiration from the posterior iliac bone, often performed by hematologists and oncologists). Today, physicians from many specialties perform musculoskeletal biopsy. Using the Medicare database, we sought to determine which specialties are performing the majority of these biopsies and to assess any trends in practice over time.
Materials and methods
Data were obtained from the U.S. Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary Master Files for 1996, 1997, 1998, 1999, 2000, 2001, 2002, and 2003. These files are aggregates of all Medicare Part B billing claims for services performed nationwide by physicians for beneficiaries enrolled in the traditional fee-for-service Medicare program. The files classify each physician service by type of procedure, using CPT-4 codes, and by specialty of the physician provider, using one of 107 CMS specialty codes. The database includes both inpatient and outpatient procedures. Use of this database, which contains no patient identifiers, is exempt from institutional review board review.
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Table 1
Definitions of CPT-4 Surgical Codes for Musculoskeletal Biopsies Used for Data Analysis
Descriptor CPT-4 Codes Marrow aspiration 38221 Muscle biopsy 20200, 20205, 20206 Percutaneous bone biopsy 20220, 20225 Open bone biopsy (nonspine) 20240, 20245 Open spine biopsy 20250, 20251
The descriptor listed in the left column is the label used for a specific category or grouping of musculoskeletal biopsies that are represented by the CPT code(s) listed in the right column.
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Results
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Table 2
U.S. Provider Distribution for Musculoskeletal Biopsy for 1996 Based on CMS Medicare Database
Provider Marrow Aspiration Muscle Biopsy Percutaneous Bone Biopsy Open Bone Biopsy (nonspine) Open Spine Biopsy RAD — 2,788 9,259 61 92 FAM PRAC — 94 134 21 83 HEM ONC — 71 7,217 342 10 INF DIS — 1 59 0 0 MED ONC — 2 880 19 0 MULTI SP — 574 1,172 113 25 NEURO SURG — 574 94 36 151 ORTHO SURG — 489 1,983 1,246 322 POD — 38 167 89 1 SURG ONC — 90 7 16 3 OTHER SURG — 4,950 542 566 66 OTHER — 1,417 3,415 583 228 Total — 11,088 24,929 3,092 981
Codes in the dataset were categorized as follows: family practice (FAM PRAC), hematology/oncology (HEM ONC), medical oncology (MED ONC), infectious diseases (INF DIS), orthopedic surgery (ORTHO SURG), neurosurgery (NEURO SURG), surgical oncology (SURG ONC), podiatry (POD), radiology (RAD), multispecialty groups (MULTI SP), other surgical speciality (OTHER SURG), and other unspecified speciality (OTHER).
Table 3
U.S. Provider Distribution for Musculoskeletal Biopsy for 2003 Based on CMS Medicare Database
Provider Marrow Aspiration Muscle Biopsy Percutaneous Bone Biopsy Open Bone Biopsy (nonspine) Open Spine Biopsy RAD 755 4,761 14,830 48 54 FAM PRAC 588 57 130 5 7 HEM ONC 80,038 28 1,048 133 0 INF DIS 149 0 4 2 0 MED ONC 23,428 0 328 3 0 MULTI SP 549 296 178 108 0 NEURO SURG 27 591 2,296 35 790 ORTHO SURG 204 537 6,879 1,369 1,212 POD 2 42 408 168 1 SURG ONC 29 41 8 14 0 OTHER SURG 605 4,221 478 712 44 OTHER 32,867 1,209 1,365 468 162 Total 139,241 11,783 27,952 3,065 2,270
Codes in the dataset were categorized as follows: family practice (FAM PRAC), hematology/oncology (HEM ONC), medical oncology (MED ONC), infectious diseases (INF DIS), orthopedic surgery (ORTHO SURG), neurosurgery (NEURO SURG), surgical oncology (SURG ONC), podiatry (POD), radiology (RAD), multispecialty groups (MULTI SP), other surgical speciality (OTHER SURG), and other unspecified speciality (OTHER).
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Table 4
Percutaneous Biopsy Volume Per Provider from 1996–2003 Based on CMS Medicare Database
Provider 1996 1997 1998 1999 2000 2001 2002 2003 RAD 9,259 9,289 9,594 10,144 10,811 11,972 12,910 14,830 FAM PRAC 134 107 105 81 64 86 122 130 HEM ONC 7,217 6,242 4,822 4,095 3,191 2,883 1,779 1,048 INF DIS 59 50 38 34 14 15 13 4 MED ONC 880 846 643 623 601 482 437 328 MULTI SP 1,172 1,040 963 893 834 1,091 423 178 NEURO SURG 94 106 81 95 134 260 800 2,296 ORTHO SURG 1,983 1,798 1,577 1,480 1,429 2,018 3,815 6,879 POD 167 207 176 221 265 401 389 408 SURG ONC 7 4 9 9 6 5 4 8 OTHER SURG 542 536 491 429 442 427 453 478 OTHER 3,415 2,929 2,298 1,929 1,591 1,474 1,278 1,365 Total 24,929 23,154 20,797 20,033 19,382 21,114 22,423 27,952
Codes in the dataset were categorized as follows: family practice (FAM PRAC), hematology/oncology (HEM ONC), medical oncology (MED ONC), infectious diseases (INF DIS), orthopedic surgery (ORTHO SURG), neurosurgery (NEURO SURG), surgical oncology (SURG ONC), podiatry (POD), radiology (RAD), multispecialty groups (MULTI SP), other surgical speciality (OTHER SURG), and other unspecified speciality (OTHER).
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Table 5
Muscle Biopsy Volume Per Provider from 1996–2003 Based on CMS Medicare Database
Provider 1996 1997 1998 1999 2000 2001 2002 2003 RAD 2,788 2,780 3,041 3,249 3,519 3,912 4,190 4,761 FAM PRAC 94 86 65 67 74 70 52 57 HEM ONC 71 80 76 57 59 55 38 29 INF DIS 1 1 4 0 0 0 0 0 MED ONC 2 12 11 6 3 7 2 0 MULTI SP 574 559 569 581 589 785 460 296 NEURO SURG 574 455 504 505 490 457 532 591 ORTHO SURG 489 510 434 400 446 466 540 537 POD 38 31 74 44 37 40 35 42 SURG ONC 90 100 91 48 49 45 50 41 OTHER SURG 4,950 4,579 4,214 4,019 4,142 4,108 4,113 4,221 OTHER 1,417 1,173 1,141 1,273 1,181 1,330 1,264 1,209 Total 11,088 10,366 10,224 10,249 10,589 11,275 11,276 11,783
Codes in the dataset were categorized as follows: family practice (FAM PRAC), hematology/oncology (HEM ONC), medical oncology (MED ONC), infectious diseases (INF DIS), orthopedic surgery (ORTHO SURG), neurosurgery (NEURO SURG), surgical oncology (SURG ONC), podiatry (POD), radiology (RAD), multispecialty groups (MULTI SP), other surgical speciality (OTHER SURG), and other unspecified speciality (OTHER).
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Discussion
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