Surgical centers that set up off-site laboratories to provide pathology services will have a harder time profiting from such arrangements under new anti-markup rules announced last week.

Many urology and gastroenterology practices have established off-site labs known as "pods" or "condos" that employ part-time pathologists and let the surgeon serve as a billing group. CMS's expansion of the Medicare anti-markup rule could end many of these arrangements by eliminating the profit margin for the billing group, says Nora Liggett, a healthcare lawyer with Waller Lansden Dortch & Davis in Nashville.

Previously, the Medicare anti-markup rule prohibited a physician from marking up the technical component of certain diagnostic tests purchased from or reassigned by outside suppliers, says Ms. Liggett. CMS has revised and expanded the anti-markup rule to apply also to the professional component of diagnostic tests as well as to technical services that are not performed in the office of the billing physician, she adds.

Put simply, if the pathologist reading the biopsy is not on-site where the doctor is practicing, these anti-markup rules will apply, says Ms. Liggett. She explains that the anti-markup rule limits the amount a physician can bill to the lower of:

Nearly two out of three colonoscopy reports delivered to primary care physicians do not conform to current guidelines for repeat testing, according to a study to be published in the December issue of the American Journal of Preventive Medicine.

The study found that endoscopists, in their correspondence with a patient's primary care provider, were most likely to recommend repeat screenings for colorectal cancer sooner than advised by the U.S. Multi-Society Task Force on Colorectal Cancer and by the American Cancer Society, which updated their guidelines in 2006.

"Frequently, [the endoscopists] were making premature recommendations without the biopsy report," says Alex Krist, MD, MPH, a family physician and one of the authors of the study that looked at the records of 3,000 patients from 10 family care practices in Virginia and Maryland.

Dr. Krist and his colleagues at Virginia Commonwealth University in Richmond also found that in 12 percent of the cases in which polyps were found, the endoscopist's communication didn't include a pathology report.

Dr. Krist says that he had no way of knowing whether practice management software was used to generate the letters, but added that it seemed many of the letters reviewed had a boilerplate format. If that's the case, the standard text could be modified to include more information, says Dr. Krist, who maintains that his study is an examination of potential communication difficulties between specialists and primary care physicians, not a rebuke to endoscopists.

Continuous peripheral nerve blockage is effective for controlling the pain and decreasing the discharge times of pediatric patients following orthopedic procedures, according to researchers at the Children's Hospital of Philadelphia.

CPNB has been used successfully on adult patients for years but little had been known about the technique's efficacy on children, say the researchers.

"The main advantage is that the [pediatric] patients can leave the hospital sooner," says Arjunan Ganesh, MD, a pediatric anesthesiologist at CHOP and lead author of the hospital's research, published in the November 2007 issue of the journal Anesthesia & Analgesia. "And, you are able to ensure better pain control and to decrease use of opioids and their side effects, such as itching and nausea."

Physicians at CHOP studied the outcomes of 217 children, aged 4 years to 18 years, who received CPNB between 2003 and 2006. Catheters placed in the study's patients delivered 0.125% bupivacaine, 0.1% ropivacaine or 0.15% ropivacaine at a rate of 2ml/h to 12ml/h, based on the patients' weight, for a mean duration of 48 hours. Fifty-six percent of patients did not require opioids in the first eight hours after surgery, 26 percent remained opioid-free 24 hours after surgery and 21 percent were still without pain medication at 48 hours post-op. Post-op nausea and vomiting occurred in 14 percent of the patients.

Dr. Ganesh says pediatric cases are done under general anesthesia, eliminating the possibility of feedback obtained from patients who are awake, namely pain and paresthesia upon placement of the blocks. He also says little is known about how pediatric patients and their families follow at-home directions to avoid potential complications that include difficulty in removing the catheter, inadequate analgesia and leakage from insertion.

Despite these potential hurdles, and the study's overall block failure rate of 15 percent, Dr. Ganesh says it is feasible to implement a CPNB program for children after orthopedic surgery when appropriate expertise is available. He adds that the technique can be used following other procedures performed on the extremities where a significant amount of postoperative pain is expected.