We appreciate the thoughtful perspective of Drs Haque and Perrino on the nuances involved in using Current Procedural Terminology (CPT) codes to characterize a health service as low value. As they note, of the 6 CPT codes used to identify a low-value spinal injection for low back pain, a single code (64493) is shared by 2 procedures: facet joint injections and medial branch nerve block.1 Although there is weak evidence to recommend the use of facet joint injections in the treatment of low back pain,2 medial branch nerve block is now more commonly used in preparation for radiofrequency ablation. In fact, the American Society of Pain and Neuroscience had made it a grade 1A recommendation for the treatment of low back pain without radiculopathy.3
In our study,1 we performed additional analyses to determine how removing CPT code 64493 would affect the estimate for low-value spinal injections. Of the 72 659 low-value spinal injections identified, 26 363 (36%) corresponded to CPT code 64493. After excluding this code, the revised count of low-value spinal injections was 0.9 per 100 veterans (previously, 1.4 per 100 veterans), at a total cost of $23.7 million (previously, $43.9 million). After excluding this code, most procedures initially identified as low value would still have been characterized as such, and the costs associated with this service still represented a substantial expenditure by the VA compared with other low-value services. It is important to note that the exclusion of CPT code 64493 would likely represent an undercount of low-value spinal injections given the exclusion of facet joint injections.
This situation highlights a potential limitation in using administrative data alone to characterize a health service as low value. It is critical that approaches for minimizing low-value care in clinical practice be estimated with accurate and valid metrics.4 Highlighting this unique circumstance in which a low-value procedure shares a CPT code with a potentially indicated procedure is an example of the type of feedback that is needed to achieve this objective.
Footnotes
Conflict of Interest Disclosures: None reported.
Disclaimer: The views expressed in this letter are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the US government.
Contributor Information
Thomas R. Radomski, Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Elijah Z. Lovelace, Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
Carolyn T. Thorpe, Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill.
References
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