Question about logging for ACGME

[thedrjojo]

So I have been trying to log my cases as I go (up to 9 now... woo) and there is little guidance in the way of what codes I should actually use. Usually if I can't find it I google search and find something to use.

Lipoma (i've done 3 thus far, 2 back, 1 with arm, back, thorax). The back i've logged as CPT 21930 Excision, tumor, soft tissue back or flank. That seems fine (and is credit for skin, soft tissue, and breast). But for the ones on the thorax, my search came up with CPT 21555 Excision tumor, soft tissue of neck or thorax, subcutaneous, which gives me credit for head and neck? I'm not gonna argue since my program has trouble with head and neck numbers at times, but i found this pretty weird. Does anyone have a better code for lipoma of the chest wall?

Hernias are straight forward (49055 for inguinal, 49570 for epigastric, 49585 for umbilical).

Colonoscopies also pretty straight forward (we took a biopsy each time so used 45380)

I placed a chest tube bedside for pneumothorax (medicine dropped a lung placing a subclavian line). Trying to find out how (or if you guys would even recommend me logging it - I haven't been keeping track of I&D's that i've done) and the best I could find was 32422, Thoracentesis with insertion of tube, includes water seal (eg, for pneumothorax). This codes as critical care (not for major credit) - so is this correct log, and if so, is it worth it to log it? Same with central lines, do you use 36556 (or 36555 for less than 5 year old) in which case it codes as misc and not for major credit, and do you even log them? Is there a minimal number of each chest tubes and central lines residents need to get, or is it just recommended?

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[glade]

Chest tube: 32551 Tube thoracostomy, includes water seal (eg, for abscess, hemothorax, empyema), when performed (separate procedure)

Note, that won't get you major credit.

Central lines should be recorded, even though they don't give you major credit. You can use it to demonstrate proficiency for privileges later on. Even if by that point you haven't done a line in years. HO HO HO!

I sort of never figured out the "right" way to log lipomas or sebaceous cysts. The problem with the logging system is basically you have to think of the most convoluted way to refer to a procedure. Also, it leaves a lot of room for interpretation. I think as long as you can theoretically justify why you logged something the way you did, you're OK. (You should see some of the B.S. I logged under operative trauma. It's hilarious.)

 

[SLUser11]

So I have been trying to log my cases as I go (up to 9 now... woo) and there is little guidance in the way of what codes I should actually use. Usually if I can't find it I google search and find something to use.

Lipoma (i've done 3 thus far, 2 back, 1 with arm, back, thorax). The back i've logged as CPT 21930 Excision, tumor, soft tissue back or flank. That seems fine (and is credit for skin, soft tissue, and breast). But for the ones on the thorax, my search came up with CPT 21555 Excision tumor, soft tissue of neck or thorax, subcutaneous, which gives me credit for head and neck? I'm not gonna argue since my program has trouble with head and neck numbers at times, but i found this pretty weird. Does anyone have a better code for lipoma of the chest wall?

Hernias are straight forward (49055 for inguinal, 49570 for epigastric, 49585 for umbilical).

Colonoscopies also pretty straight forward (we took a biopsy each time so used 45380)

I placed a chest tube bedside for pneumothorax (medicine dropped a lung placing a subclavian line). Trying to find out how (or if you guys would even recommend me logging it - I haven't been keeping track of I&D's that i've done) and the best I could find was 32422, Thoracentesis with insertion of tube, includes water seal (eg, for pneumothorax). This codes as critical care (not for major credit) - so is this correct log, and if so, is it worth it to log it? Same with central lines, do you use 36556 (or 36555 for less than 5 year old) in which case it codes as misc and not for major credit, and do you even log them? Is there a minimal number of each chest tubes and central lines residents need to get, or is it just recommended?

You're probably loggging everything right, but as glade points out, none of those procedures count toward your "defined category for major credit" numbers. WS has noted in the past that the vast majority of the things that we do as residents won't count towards our numbers.

I thought it was pretty interesting to find out that kidney transplants don't really count for anything unless you log the iliac anastomosis for a vascular case, which is just stupid.....

Anyway, I have a cheat sheet floating around that has lots of codes on it, and I'll try to post it here soon.

 

[ESU_MD]

I always kept a separate spreadsheet of the stuff I've done in addition to the ACGME log

 

[45408]

So what's the difference between major and minor credit? They've given us precisely zero feedback/teaching on this. It's different from the distinction between surgeon junior and first assist?

 

[Winged Scapula]

Central lines should be recorded, even though they don't give you major credit. You can use it to demonstrate proficiency for privileges later on. Even if by that point you haven't done a line in years. HO HO HO!

Yeah, because you really want privileges to do central lines when in practice.🙄

Believe me, its a waste of time for very little reimbursement and in the end, its usually included in general surgery privileges anyway.

 

[glade]

Yeah, because you really want privileges to do central lines when in practice.🙄

Hey, we can't all be copping feels of women in our offices like you. Some of us have to go around doing work.

 

[glade]

So what's the difference between major and minor credit? They've given us precisely zero feedback/teaching on this. It's different from the distinction between surgeon junior and first assist?

You need 750 major cases to graduate and sit for the Boards. Minor cases don't count towards that, no matter how many you do or how much of the procedure you did. The distinction between surgeon junior and first assist is dependent on how much of a case you do. If you are mostly assisting, you shouldn't claim credit for the case, but that's a highly subjective assessment and people who are hard up for cases or who just don't care may claim credit for cases they just assisted on. That's your own call.

 

[Winged Scapula]

Hey, we can't all be copping feels of women in our offices like you. Some of us have to go around doing work.

I know you're joking but my point is that go ahead and log your central lines but most general surgeons I know aren't clamouring to put in central lines or ports. The reimbursement stinks especially when you calculate the time, the risk involved, and having to be someone's line jockey.

But hey...if being paid $122 (in Arizona) for something which is often done in the middle of the night, comes with not insignificant risk of complications when you could be doing something more highly paid in the same time frame (when you include set-up, doing it, and checking x-ray), floats your boat, go for it.

I'm just telling you what the reality is - I don't know too many general surgeons other than academic types who do central lines as a priority.

And even feeling boobs, for those who like to do it socially, loses its appeal after the 100th in a week.

 

[JackADeli]

...most general surgeons I know aren't clamouring to put in central lines or ports...

Actually.... I have been very, very surprised at the number of ports & groshongs the surgeons are putting in these days. I haven't looked at the RVU values... but. it seems like I see OB/Gyns and cardiac surgeons doing more and more of them. When I have asked, am usually told it is about reimbursement and RVUs.... it might be worth your checking it out for your cancer patients.

tunneled catheter CPT 36558 & 36561

 

[Winged Scapula]

Actually.... I have been very, very surprised at the number of ports & groshongs the surgeons are putting in these days. I haven't looked at the RVU values... but. it seems like I see OB/Gyns and cardiac surgeons doing more and more of them. When I have asked, am usually told it is about reimbursement and RVUs.... it might be worth your checking it out for your cancer patients.

tunneled catheter CPT 36558 & 36561

I *have* checked it out and because of that no longer put them in. The reimbursement here is just slightly over $350 here for placement of a tunneled port in an adult.

We've had that discussion here before; as I recall Sluser or perhaps SocialistMD was stating that his attendings were being paid $1000 for the procedure. I suggested that they were either upcoding or incorrectly coding and they were supposed to ask again and get specific codes for me. If you know more about it, then perhaps I am missing something JAD...ie, please ask your surgeons exactly what codes they are billing. AFAIK, even if you code for fluoro, it isn't really time efficient.

Central lines at the bedside tend to reimbursement around $120. Again, not worth my time when you consider set-up, checking Xray, etc. - I could be doing a more highly reimbursed case or even seeing several new consults in the office.

Here is the link and you can see the reimbursement for your state...remember unless you are doing them in your office, you cannot collect the non-facility fee.

Given the time it takes and the risks involved and the desire for patients to refuse a second anesthesia (ie, if I put it in at the time of their cancer surgery, I will get 50% or less of the above reimbursement), I and other surgeons here tend not to do them. It can be done in the rads suite; however, I find that many patients prefer me to take them out because they say that rads did not sedate them enough (which isn't suprising) since they aren't doing conscious sedation.

I *will* take out since the reimbursement is only slightly less, it takes much less time and has none of the complications of potential PTx, etc. that placement does.

 

[JackADeli]

...The reimbursement here is just slightly over $350 here for placement of a tunneled port in an adult.

We've had that discussion here before; as I recall ...attendings were being paid $1000 for the procedure. ...If you know more about it, then perhaps I am missing something JAD...ie, please ask your surgeons exactly what codes they are billing...

...I could be doing a more highly reimbursed case or even seeing several new consults in the office...

Given the time it takes and the risks involved ...I and other surgeons here tend not to do them...

I will check with some attendings and figure out what it is.... I just noticed recently that even OB/Gyn has started placing them with the reasoning being RVUs and such.

I somewhat remember said previous discussion.

I don't know exactly what the reimburse is.... it may be an issue of the RVU to time used ratio that has them clammeri9ng for a quick groshong/broviac. I think it is more to their benefit when they have several rooms and can squeeze in these between cases????

I too do not plan to do them for the risk concerns/etc... but am curious. I will ask about it this week if I get a chance and bump into one of those guys....

Oh, final note, another reason I do not plan to do them is I really do not want the calls of occluded and/or non-functional ports and lines....

 

[45408]

You need 750 major cases to graduate and sit for the Boards. Minor cases don't count towards that, no matter how many you do or how much of the procedure you did. The distinction between surgeon junior and first assist is dependent on how much of a case you do. If you are mostly assisting, you shouldn't claim credit for the case, but that's a highly subjective assessment and people who are hard up for cases or who just don't care may claim credit for cases they just assisted on. That's your own call.

When logging them, do they say if they're major or minor?

 

[Winged Scapula]

When logging them, do they say if they're major or minor?

You don't have to...the CPT code will determine that.

ABS has a list of what major cases are...your residency PC should be able to provide it to you if you can't find it on their website.

 

[45408]

SLUser - ever find that cheat sheet you made up?

These are the ones I've been making good use of:


Non-operative trauma - 99199
Critical care – 99292
Chest tube – 32551
Art line (radial) – 36620
Central line – 36556

 

[SocialistMD]

Lipoma (i've done 3 thus far, 2 back, 1 with arm, back, thorax). The back i've logged as CPT 21930 Excision, tumor, soft tissue back or flank. That seems fine (and is credit for skin, soft tissue, and breast). But for the ones on the thorax, my search came up with CPT 21555 Excision tumor, soft tissue of neck or thorax, subcutaneous, which gives me credit for head and neck? I'm not gonna argue since my program has trouble with head and neck numbers at times, but i found this pretty weird. Does anyone have a better code for lipoma of the chest wall?

Ask your attending. The CPT codes are the same ones they use for billing. Many attendings know the CPT codes for the common procedures they perform. If your attending doesn't know, ask someone in his/her office who does his/her billing how they code them. Yes, it is more work and less fun than trying to figure out how to code everything, but you'll at least code it correctly. I wouldn't worry about the major/minor credit thing as an intern; you'll get all of your cases.

Also, make it a habit of writing down the codes in your sticker book/however you do it; it will allow you to find some of those codes for procedures that have codes that are difficult to find by a regular search (i.e. 45990 for rectal/anal EUAs).

 

[SLUser11]

SLUser - ever find that cheat sheet you made up?

I didn't make this cheat sheet, so it may not be perfect. However, this one is a scanned version of my personal copy, so I can assure you that most of the codes are up to date. Try to ignore my scribble that you can kind of see on the back....that was during my intern orientation 4 years ago and is a reflection of my attention span.

 

[45408]

Thanks 😀

anyone ever log a 55970?

 

[SLUser11]

Thanks 😀

anyone ever log a 55970?

Insert mom joke here.

 

[deleted89854]

After losing a big pile of stickers halfway through intern year, I've become neurotic about logging onto ACGME after doing the dictation and logging the case. Usually anesthesia requires a CPT code from the surgery attending for documentation purposes. I usually ask them if I can't figure it out (that search function is indeed a big piece of crap). Is there really any benefit to logging chest tubes, I&Ds, or lines? I'm not sure I see a reason to bother with it.

 

[45408]

Insert mom joke here.

Well, she used to be your dad.

 

[45408]

After losing a big pile of stickers halfway through intern year, I've become neurotic about logging onto ACGME after doing the dictation and logging the case. Usually anesthesia requires a CPT code from the surgery attending for documentation purposes. I usually ask them if I can't figure it out (that search function is indeed a big piece of crap). Is there really any benefit to logging chest tubes, I&Ds, or lines? I'm not sure I see a reason to bother with it.

this -

Central lines should be recorded, even though they don't give you major credit. You can use it to demonstrate proficiency for privileges later on. Even if by that point you haven't done a line in years. HO HO HO!

I doubt it matters too often, but I'll probably log them just the same.

 

[Winged Scapula]

this -

I doubt it matters too often, but I'll probably log them just the same.

Feel free to log those cases but I can tell you I have surgical privileges at 8 hospitals and several surgery centers and ALL of them include such things in GS privileges. There are only a certain few things where you have to document with a case log the number you have done (ie, sentinel node biopsy, use of C02/YAG lasers, some vascular privileges, conscious sedation, etc.).

 

[Guile]

I didn't make this cheat sheet, so it may not be perfect. However, this one is a scanned version of my personal copy, so I can assure you that most of the codes are up to date. Try to ignore my scribble that you can kind of see on the back....that was during my intern orientation 4 years ago and is a reflection of my attention span.

You have lap adrenalectomy on your cheatsheet? How many of those have you gotten? This is a good list. Thanks.

 

[SLUser11]

You have lap adrenalectomy on your cheatsheet? How many of those have you gotten? This is a good list. Thanks.

Three (First assisted one, surgeon juniored two)...all trans-abdominal, no retro-peritoneal. I've done a couple open as well, and I'm relatively familiar with the retroperitoneum from multiple nephrectomies (mostly open, several lap donor, several radical open with a couple lap radical).

But you're right, it's uncommon...it's there more for completeness than anything else...besides, it's not my list. I just got it as an intern.

 

[Guile]

Three (First assisted one, surgeon juniored two)...all trans-abdominal, no retro-peritoneal. I've done a couple open as well, and I'm relatively familiar with the retroperitoneum from multiple nephrectomies (mostly open, several lap donor, several radical open with a couple lap radical).

But you're right, it's uncommon...it's there more for completeness than anything else...besides, it's not my list. I just got it as an intern.

Wow, and you've still got it as a chief, like a boss.

Yeah we only do about 50 or so adrenals per year here. I think our guys like the retro-peritoneal approach more. I haven't scrubbed one yet.

 

[45408]

Old thread, I know, but question on the same topic...


So, if I do the groin exposure for an EVAR, there's a code for that (34812 - Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral).

Are there other cases similar to that, where you're not doing the major portion of the overall case, but there's still a code you can log that still makes it a major case? I'm specifically looking at cardiac surgery. I'm not exactly sewing in the distal anastomosis or throwing down the pledgets for the AVR, but they are getting me involved. What do other people log when they rotate through CT?

 

[Buzz Me]

I forget already. But don't thoracotomies and sternotomies count towards the thoracic requirements (as well as count for your major total)?

 

[45408]

I forget already. But don't thoracotomies and sternotomies count towards the thoracic requirements (as well as count for your major total)?

Yes, they do, but since the code for a CABG entails that, I'm wondering if I can "split it up" so I'm taking credit for "median sternotomy" but not the CABG part itself. I've been doing a lot with the set-up/take-down of everything, cannulating, blah blah blah, but I'm not sewing in the grafts or really wielding a needle near the heart at all. I'm just wondering how people would log this so that they could get credit for doing something, because you can get credit for exposing the femoral artery for an EVAR, even if you didn't do the EVAR.

 

[Smurfette]

yes, you can do that. if you do the sternotomy, you can count it as a sternotomy. Dont put CABG unless you are doing that as the critical part of the procedure.

 

[45408]

What codes exactly though? I'm drawing some blanks...


I did just realize I can code for removing an IABP today, holy crap...guess I'll volunteer to remove all the balloon pumps, lol.

33968 Removal of intra-aortic balloon assist device, percutaneous THORACIC OTHER MAJOR THORACIC

 

[Smurfette]

What codes exactly though? I'm drawing some blanks...


I did just realize I can code for removing an IABP today, holy crap...guess I'll volunteer to remove all the balloon pumps, lol.

33968 Removal of intra-aortic balloon assist device, percutaneous THORACIC OTHER MAJOR THORACIC

That's a better question for BuzzMe, but a quick google search gave me this:

39010 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, including either transthoracic or median sternotomy

"Exploration" is pretty generic so that should work for your case log purposes.

 

[thedrjojo]

What codes exactly though? I'm drawing some blanks...


I did just realize I can code for removing an IABP today, holy crap...guess I'll volunteer to remove all the balloon pumps, lol.

33968 Removal of intra-aortic balloon assist device, percutaneous THORACIC OTHER MAJOR THORACIC

Are you ****ting me? I'd have like 10 more thoracic cases if I realized this...

 

[SLUser11]

What codes exactly though? I'm drawing some blanks...


I did just realize I can code for removing an IABP today, holy crap...guess I'll volunteer to remove all the balloon pumps, lol.

33968 Removal of intra-aortic balloon assist device, percutaneous THORACIC OTHER MAJOR THORACIC

While that may be true, I always faced a personal dilemma when I saw that a minor role in a small procedure somehow counted for major credit. I didn't want to use clever coding to get my numbers. I wanted to get my numbers the old-fashioned way: by doing big cases.

 

[45408]

While that may be true, I always faced a personal dilemma when I saw that a minor role in a small procedure somehow counted for major credit. I didn't want to use clever coding to get my numbers. I wanted to get my numbers the old-fashioned way: by doing big cases.

Of course, as do I, but as you can imagine, when I'm rotating with the cardiac surgeons, they aren't just telling me "Hey, why don't you just come on up here and sew in this valve?" So I could say that I did 10% of an aortic valve, but if they let me do the majority of the exposure and cannulation and closure, then I'll claim the mediastinotomy. Was your experience different? (serious question)

I also don't make the rules, so if someone wants to give me credit for pulling the balloon pump, then I'll take it. It would be completely inadequate if you just pulled 15 balloon pumps and did no other thoracic cases, but if I'm rotating through, I'll claim what I do. Realistically, there may only be 2 more of these this month.

 

[SLUser11]

Was your experience different? (serious question)

I pretty much avoided the hearts and focused on thoracic cases. I doubt I would have been allowed to sew on a cardiac case, but I certainly got to do most of the thoracic cases.

 

[45408]

I pretty much avoided the hearts and focused on thoracic cases. I doubt I would have been allowed to sew on a cardiac case, but I certainly got to do most of the thoracic cases.

Avoiding the hearts isn't much of an option, unfortunately. There's probably a 3:1 ratio of cardiac to thoracic cases. I'll just take what I can get.

 

[ACSurgeon]

While that may be true, I always faced a personal dilemma when I saw that a minor role in a small procedure somehow counted for major credit. I didn't want to use clever coding to get my numbers. I wanted to get my numbers the old-fashioned way: by doing big cases.

That's great in theory, but as a junior, if you spend several hours scrubbed in a major case and do small parts of it, I think it's ok to code what you can. I've been told to code exploratory laparoscopy when I scrub complex laparoscopic cases that I get to do little operating in, for example.

We all want to get the best training we can, but ultimately, you have to get your numbers to graduate, and I don't think anyone is interested in extending their training because they didn't get enough thoracic numbers.

 

[SLUser11]

That's great in theory, but as a junior, if you spend several hours scrubbed in a major case and do small parts of it, I think it's ok to code what you can. I've been told to code exploratory laparoscopy when I scrub complex laparoscopic cases that I get to do little operating in, for example.

We all want to get the best training we can, but ultimately, you have to get your numbers to graduate, and I don't think anyone is interested in extending their training because they didn't get enough thoracic numbers.

So, you are logging "diagnostic laparoscopy" as surgeon junior when truthfully you are holding the camera on a gastric bypass?

If you are having to fudge your numbers to get the 15 thoracic cases required to graduate, it suggests a problem with your program's rotation structure that they need to be aware of.

That's sort of my point. Fudging the numbers prevents the program director from identifying areas of weakness.

 

[Dirt]

Honest question after reading this thread.

As an intern I have essentially been logging every case that is the attending and I as surgeon junior, pretty much regardless of how much of the case I did. Is this wrong?

For example if I do a CEA, and do most of the initial dissection, then the attending does the endarterectomy and patch, and then I close, am I wrong to log that as a surgeon junior case?

I have generally been reserving first assist for cases that I double scrubbed with an attending and a higher level resident.

 

[45408]

So, you are logging "diagnostic laparoscopy" as surgeon junior when truthfully you are holding the camera on a gastric bypass?

That's sort of my point. Fudging the numbers prevents the program director from identifying areas of weakness.

I definitely don't log "diagnostic laparoscopy" for all of the complex lap cases that I didn't do anything for, even though I probably did obtain the access and place most of the ports. I might even forget to log "first assist" for those. I mostly just dislike being put in a case where the attending doesn't plan to let you do anything (gastric bypasses being the worst offenders).

Honest question after reading this thread.

As an intern I have essentially been logging every case that is the attending and I as surgeon junior, pretty much regardless of how much of the case I did. Is this wrong?

For example if I do a CEA, and do most of the initial dissection, then the attending does the endarterectomy and patch, and then I close, am I wrong to log that as a surgeon junior case?

I have generally been reserving first assist for cases that I double scrubbed with an attending and a higher level resident.

The ACGME has always been pretty vague about what exactly they want. Take a look at how much there is(n't) about exactly how to log these things on their website. We end up picking things up from our seniors and SDN. The SDN mantra has been "you should do 51% of the case to log it," and I mostly agree. The ACGME doesn't just consider whether or not you did the operation though - there's something in there about whether or not you had a "substantial role in the pre-operative evaluation, peri-operative management and post-operative care" as well. Is any of that quantified? Not that I know of...

Only links I can find are: http://www.acgme.org/acgmeweb/tabid...Accreditation/Surgery/CaseLoginformation.aspx and the very vague "guide to entering cases" once you've logged in.

 

[45408]

This document references plastic surgery residents, but it seems like the same guidelines apply: http://www.acgme.org/acgmeweb/Porta...rces/360_Surgeon_Definition_for_Case_Logs.pdf

To be recorded as the resident "surgeon" in the ACGME Resident Case Log System, a resident must be present for all of the critical portions of the procedure being logged, under the supervision of an attending surgeon. Involvement in the pre-operative assessment, intra-operative planning, and the post-operative management of that patient is critical to that participation.

To be recorded as a resident "assistant" in the ACGME Resident Case Log System, a resident must be an active participant in the operative procedure. The attending surgeon remains responsible for resident supervision and patient care.

This would go against the "Did you do at least 51% of the operation?" because all it says is that you have to be present for the operation.

 

[SLUser11]

Honest question after reading this thread.

As an intern I have essentially been logging every case that is the attending and I as surgeon junior, pretty much regardless of how much of the case I did. Is this wrong?

For example if I do a CEA, and do most of the initial dissection, then the attending does the endarterectomy and patch, and then I close, am I wrong to log that as a surgeon junior case?

I have generally been reserving first assist for cases that I double scrubbed with an attending and a higher level resident.

First assist is appropriate for cases where it's you and the attending, but the attending is performing the critical portions of the case. If you're double scrubbed, then really you are second assist.

You should definitely not log every case you do as surgeon junior, as it's dishonest. I know it's unintentional, though, so I'm not questioning your ethics. What I'm learning in this thread is that there needs to be more formal instruction on how and what to log.

I think it's doing you a disservice to have you scrubbing in cases like that above your level where you aren't getting to do much.

I'm not sure I agree. Assisting on the big cases makes you better prepared to do the operation as surgeon junior when the time arrives.

I agree that the instructions from the ACGME are too vague, but as the Prowler mentioned, the rule of thumb is to log it as surgeon junior if you perform greater than 50% of the case, including the critical portions. Stick to that approach, and you should still have no problem getting your numbers.

If creative logging and exaggeration of participation get you from 800 cases to 1000, then you are not just cheating yourself. You are also misrepresenting the operative experience to outsiders, which is unfair to 1) the program, who won't address the deficiencies, and 2) the interviewees, who won't learn until it's too late that they were misled.



I just looked up my old case logs, and I first assisted on about 300 cases. I was pretty good about logging these, but I just wanted to ensure that I practiced what I preach. I know this post comes off a little condescending and self-righteous, but it's important that we don't embellish our operative experience. Right now, the big shots in the ACS are making a lot of decisions about young surgeons, and it's without our input. If they find out we're doing the things mentioned in this thread, it will empower them to keep doubting our abilities.

 

[45408]

If creative logging and exaggeration of participation get you from 800 cases to 1000, then you are not just cheating yourself. You are also misrepresenting the operative experience to outsiders, which is unfair to 1) the program, who won't address the deficiencies, and 2) the interviewees, who won't learn until it's too late that they were misled.

Unfortunately, the current system makes it such that you might help future folks, but it could hurt you. I'm not disagreeing with anything you've said, but much like a whistleblower who calls for a review on their program that then loses its accreditation and the whistleblower and all other residents are out of a job, the system should try to help residents/programs before there gets to be a problem.

And I have a 2.2 to 1 ratio of surgeon junior to first assist cases. I've heard it suggested that your case log might gather attention if you don't have anything logged as a first assist.

 

[Miami_med]

I don't think it's dishonest to log something that is part of a larger case. I logged sternotomy on a number of cardiac cases. For many of them, I was there for the whole case but didn't do the anastamosis/sew in the valve. If I do a sternotomy, gain access to the pericardium, cannulate the aorta, assist in a large cardiac case, and then close, I think that it is reasonable to log sternotomy. If you really did a sternotomy, looked at the heart, and closed, and you did the whole thing, no one would give it a second thought. The fact that the attending did something in between doesn't detract from what you did.

Similarly, I have a bariatric surgeon who gives you a discreet portion of the case, creating the J-J anastamosis. If I gain access to the peritoneal cavity and create a J-J anastamosis laparoscopically, I think that it is reasonable to log it as such, regardless of whether the attending did other portions of the case at large. I did the critical portion of the case I logged.

Also, I've already met all of my numbers in all categories, most 2-3 times over. I don't need any of these to graduate. It's the principle of the matter. You should log what you do. No more, but also no less.

 

[ACSurgeon]

I guess I should clarify. We actually don't log these cases because we have to graduate, more to feel like your time standing in the OR means something. In those cases, I'll log the diagnostic lap as surgeon junior, and then the complex lap without "getting credit" (ie I don't check the box). The frequency of these cases are very low, and represent a small portion of cases, but it sucks when you scrub a case for 4+ hours and don't get to code anything as surgeon junior. But I see the counter argument...

 

[SocialistMD]

Old thread, I know, but question on the same topic...


So, if I do the groin exposure for an EVAR, there's a code for that (34812 - Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral).

Are there other cases similar to that, where you're not doing the major portion of the overall case, but there's still a code you can log that still makes it a major case? I'm specifically looking at cardiac surgery. I'm not exactly sewing in the distal anastomosis or throwing down the pledgets for the AVR, but they are getting me involved. What do other people log when they rotate through CT?

Laparoscopic mobilization of the splenic flexure.

 

[Buzz Me]

Hmmm...I wouldn't log any cases (or procedures, or steps) where I didn't do the critical portions of the procedure. I want to know exactly what kind of operating experience my program is providing, and where my technical deficiencies may be.

If I'm scrubbed in an EVAR but only do the groin cutdown and femoral vessel exposure, I'm only logging that.

For those cardiac cases that you scrub while a Gen Surg resident, I would just code for the median sternotomy - if you actually did it - which is 39010. Intra-op chest tubes are 32551, though of course those aren't counted as major cases. Otherwise, most of your thoracic requirements will come from thoracic cases - the thoracotomies and such.