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* From the Interventional Pulmonology & Critical Care Medicine Department (Dr. Lund), St. Mary’s Regional Medical Center, Lewiston, ME; and Interventional Pulmonology (Mr. Garland and Dr. Ernst), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
Correspondence to: Armin Ernst, MD, FCCP, Chief, Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Rd, Boston, MA 02215; e-mail: aernst{at}bidmc.harvard.edu
Abstract
Background: Airway stenting is a procedure that is performed increasingly often, and the availability of metallic stents placed by flexible bronchoscopy may have contributed to the increased usage. These procedures have an impact on the required physician skill set and practice management. We review the indications for airway stenting, and how the requirement of combined therapies and technical aspects of central airway stenting pertain to practice management.
Procedure: We compared several reimbursement scenarios for managing stent placement using the Centers for Medicare and Medicaid Services relative value units (RVUs) and average reimbursement amounts. We also compared the reimbursement to other commonly performed activities performed by pulmonary and critical care physicians. An analysis of Medicare facility outpatient and inpatient payment for procedures using silicone and metallic stents was also conducted.
Results: Professional reimbursement is identical regardless of stent type, method of insertion, and anesthesia administered. The net facility reimbursement largely depends on stent costs. The RVUs alone are a poor comparator for the reimbursement of therapeutic bronchoscopy because of Correct Coding Initiatives edits. Considering the time necessary for performing advanced therapeutic bronchoscopy, the professional fees are not attractive. The net facility reimbursement largely depends on stent costs.
Conclusion: The placement of airway stents is not reimbursed at competitive rates and may even lead to a net loss for the facility. The practice management benefits of central airway therapy are probably best obtained by a multidisciplinary airway team with an established cost center structure.
Key Words: airway stenosis • airway stenting • bronchoscopy • interventional pulmonology • practice management
The incidence of central airway obstruction (CAO) is unknown, but an estimated 30% of all lung cancer patients will experience endobronchial disease, which is a major source of CAO.12345 Minimally invasive therapies can be crucial for patients with inoperable disease or limited pulmonary function.6 Numerous studies789101112 have reported that endobronchial therapies, including airway stenting, can palliate symptoms in 80 to 97% of patients with dyspnea. Advanced knowledge and skills are required to insert these stents, and the ability to perform emergency procedures and procedures that require general anesthesia are necessary.
The overall management of CAO has been reviewed.13 Here, we review the indications and procedures for inserting stents and illustrate the associated issues with reimbursement.
Indications for Stenting
The primary indications for stenting are (1) clinically important extrinsic compression on the central airways, and (2) the presence of a mixed lesion with persistent luminal compromise after the ablation of endoluminal disease. However, stents are rarely necessary in patients with solitary endoluminal disease; malignant endobronchial disease is best treated with tumor ablation or resection. A rapidly recurring tumor with repeated obstruction may benefit from placement of a stent to mitigate airway compromise.
The standard of practice for nonmalignant CAO remains surgical resection; therefore, all patients should be evaluated by a surgeon who is experienced in complex airway reconstruction.6 Primary stenting can be considered in patients with definitive inoperable disease or coexistent disease that renders their condition inoperable.
A final indication for stenting includes the use of covered stents in patients with airway fistulas. In this application, stents may be employed to occlude a fistula or to use the inflammatory response and granulation tissue formation to occlude an anastomotic dehiscence after lung transplantation.7
Stent Design and Placement
Stent design and materials are critically important, but a thorough discussion of these features is beyond the focus of this article. Suffice it to say that various metals, silicone, polyester, and mixed (hybrid) materials have been used. The first metallic stent, used by Canfield and Norton in 1933, was made of silver.8 More recently, nitinol (a nickel-titanium alloy) has been used in virtually all self-expanding metallic stents. The most commonly used nitinol stent is the Ultraflex stent (Boston Scientific; Natick, MA).
Silicone stents (manufactured by Novatech [La Ciotat, France] and Bryan Corporation [Boston, MA]) require performing rigid bronchoscopy for insertion. They are available in straight tracheobronchial varieties, as well as in "Y" configurations. Hybrid stents (eg, Dynamic Stent; Boston Scientific) include metallic support structures and a silicone body.9 A newer hybrid stent (Polyflex Stent; Boston Scientific), is composed of a woven polyester mesh and a full-length silicone membrane. The Polyflex stent also requires performing rigid bronchoscopy for placement.
Although metallic stents have become popular because of their simple deployment with flexible bronchoscopy, they are generally unsuitable for applications in patients with benign disease.10 For the most part, only covered, self-expanding metal or silicone stents are appropriate for use in patients with malignant disease.
Rigid bronchoscopy is generally necessary to place stents in patients who have other than routine malignant tracheobronchial disease. Rigid bronchoscopy requires either a state-of-the-art bronchoscopy suite equipped to provide anesthesia or an operating room. However, few interventionalists have enough case volume to request blocks time in an operating room. The resulting uncertainty in procedure scheduling may cause issues with more easily arranged clinic schedules. Dedicating one or two half-days a week for procedures allows more consistent scheduling, but it does not eliminate the issues of operating room availability.
Necessity of Combined Therapies
In managing CAO, combined therapies are routinely required to obtain the best outcomes. For example, endobronchial disease is effectively controlled with Nd-YAG laser ablation, argon plasma coagulation, electrocautery, microdebridement, endobronchial injections/topical applications11121314 or coring out, among other technologies.
Balloon bronchoplasty or tracheoplasty to dilate the stenotic airway is usually required to prepare a trachea with high-grade stenosis for stenting or for assisting in stent opening after deployment. In emergencies, a rigid bronchoscope can be used to dilate the central airways. Balloon bronchoplasty decreases the shearing forces, and induces less mucosal and submucosal trauma, potentially decreasing the likelihood of granulation tissue formation and the occurrence of restenosis.15 Thus, it is obvious that airway stenting in a pulmonary practice requires expertise with other procedures and a substantial capital investment (eg, for thermal ablation technology, bronchoscopes, and rigid bronchoscopy equipment).
The overall incidence of complications in a multimodality interventional program is 4 to 7%.111617 Complications of stenting include migration, mucus impaction, tumor ingrowth or overgrowth, stent fracture, and exuberant granulation tissue. The indication for stenting is associated with the incidence of granulation tissue.18 Stents placed for treatment of malignancy develop granulation at a rate of 4%, a rate that is strikingly different from the 17% rate in lung transplant strictures and the 33% rate in other benign CAOs. The removal of metallic airway stents is commonly associated with complications, including death.19
The risk of complications and the need to perform additional procedures, such as endobronchial ablation, may also affect practice overhead because medical malpractice insurance companies may raise premiums for performing advanced therapeutic procedures. An approach to stenting nonmalignant and malignant CAOs is presented in Figures 1and 2 .
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As outlined above, stenting is medically complex, and its practice implications are therefore complicated. The procedure may be performed in the following different places of service (POSs): with the patient either under moderate sedation in an endoscopy unit or operating room or under general anesthesia in the operating room; and with either flexible or rigid bronchoscopy. Airway stenting is generally part of a multimodal approach to treating airway disease, so managing thoracic malignancies and the financial impact of stenting alone need to be placed into this context.
The finances of stenting and interventional bronchoscopy differ greatly between a multidisciplinary disease management team and a physician in private practice. We will focus on the issues of reimbursement for practice-employed physicians. Facility reimbursement, which becomes more complicated as coding systems and payment methods often change with POS, will be discussed after this section.
The issues of physician reimbursement are best addressed with a unified benchmark. The Medicare physician fee schedule (MPFS), which is administered by the Centers for Medicare and Medicaid Services (CMS), is in the public domain, and variations of it are widely used by commercial insurance plans and other government payers. For these reasons, the MPFS is used as the benchmark.
In 1992, Medicare changed physician payment from charge-based to a resource-based relative value scale fee schedule. The method involves dividing a service into three components (ie, physician work, practice expense [PE], and malpractice insurance), and determining the cost of the components, establishing relative value units (RVUs) for the service, and applying a monetary conversion factor (determined by Congress) that converts RVUs into dollars and maintains budget neutrality for the Medicare pool of physician services.
As a result of resource-based methodology, procedures that can be performed in a physician’s office as well as in a hospital have two PE RVUs (ie, nonfacility and facility). The nonfacility setting includes physicians’ offices, patients’ homes, freestanding imaging centers, and independent pathology laboratories. Facility settings include hospitals, Medicare-certified ambulatory surgery centers, and skilled nursing facilities. Because the PEs for services provided in a facility setting are generally included in the payment to the facility (rather than the payment to the physician under the fee schedule), the PE RVUs are generally lower for services provided in the facility setting.16 A physician performing a procedure in a hospital outpatient bronchoscopy suite would submit the claim with a POS code of 22 along with outpatient and bill type code13X, indicating a hospital outpatient, and would be paid the facility-setting physician fee. If the procedure is performed in a freestanding physician-owned center, the practice would submit the bill with a POS code of 11, indicating office, and a bill-type clinic code, and would be paid the non–facility-setting physician fee. Table 1 shows the difference between nonfacility and facility total RVUs and payment for select bronchoscopy services. Most interventional bronchoscopies will be performed in a hospital; therefore, the majority of physicians in practice will be billing based on the MPFS facility setting rules.
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The special rules for multiple endoscopic procedures further impact the reimbursement of these potentially long and complicated bronchoscopic procedures. Endoscopy codes are grouped into families with other related endoscopic CPT codes. Each endoscopic family has a base code. When a procedure is billed with another endoscopy procedure in the same family (ie, has the same base code), the multiple endoscopy rule applies. Medicare will allow payment in full for the one code that has the highest allowance, and will allow payment for the second and subsequent same family codes at their allowed amount minus the allowed amount for the base code. (Note: check CCI edits first to ensure that only comprehensive codes are being reported.20) When evaluating the reimbursement of the multiple procedures involved in therapeutic bronchoscopy, reimbursement becomes progressively lower. For example, if an interventional bronchoscopy procedure requires the destruction of a tumor (CPT code 31641) followed by a bronchoplasty with stent placement in the bronchus (CPT code 31636), the reimbursement is substantially lower then when each procedure is performed individually.
According to CCI edits, neither code is a component of the other (nor are they mutually exclusive); therefore, both tumor ablation (CPT code 31641), with a 2006 Medicare national average payment of $275.14, and bronchial stenting (CPT code 31636) can be reported. This procedure, without tumor ablation, would reimburse $241.79, which is the 2006 Medicare national average payment. However, as a secondary code in the same family as the tumor ablation that is performed by the same physician on the same patient on the same day, the allowed amount is reduced by the amount allowed for the base procedure. In this case, the 2006 Medicare national average payment of $152.35 for the base procedure (bronchoscopy [CPT code 31622]) would be subtracted from $241.79, which is the fee for the stenting procedure. So, in this example, the additional reimbursement for CPT code 31631 is only $89.44, providing a total of $364.58 for the entire procedure, compared to $516.93 if the procedures were additive when performed sequentially during the same bronchoscopy.
When medically indicated, the use of an add-on-coded procedure will affect reimbursement. For example, the use of endobronchial ultrasound (EBUS) [CPT code 31620] to determine the extent of submucosal disease and the correct length of a stent is billed as an additional charge.21 Add-on codes must be reported in conjunction with other codes (eg, EBUS may be reported in conjunction with CPT codes 31622 to 31646).22 Under the MPFS, add-on codes are exempt from special rules for multiple endoscopic procedures and other multiple discounting rules. By using EBUS in the previous example, the effect of the add-on code is to increase the reimbursement by $78.07, for a total multiple procedure reimbursement of $442.65.
The preceding examples are based on payment amounts allowed by the CMS. Payment from non-Medicare payers may differ substantially. Further, while the Health Insurance Portability and Accountability Act has come a long way in establishing standard code sets and claim forms, third-party payers often exercise independence in their coding and payment directives.
The complexities of stenting require facility with both rigid and flexible bronchoscopy that is dependent on the airway disease and stent type required. Unfortunately, the additive skill, risks, and limited pool of technical competency in performing rigid bronchoscopy are not recognized by the current RVU scale. Professional reimbursement is the same for flexible and rigid bronchoscopy (CPT code 31622). While the professional service for administering general anesthesia is considered for separate payment, there is no separate payment for administering moderate sedation.
Facility Reimbursement
Differences in coding systems and payment methodologies contribute to the complexity of facility payment (Table 4 ). Regardless of the differences in Table 4, the fact that the type of stent placed substantially affects the net reimbursement holds true for both outpatient and inpatient facility payment. In Table 5 , we show the effect of stent selection on facility payment under the Medicare Hospital Outpatient Prospective Payment System (HOPPS). The average metallic stent costs $1,800, while silicone stents cost $250 to $600. Therefore, using rigid bronchoscopy to place a silicone stent in the bronchus (CPT code 31636) could increase the net reimbursement by $1,063.54. When placing a second stent in a separate central airway, a second CPT code (31637) is used. This addition can magnify the differential cost of the self-expanding metallic stents because the ambulatory payment classifications (APCs) to which CPT codes 31636 and 31637 are assigned are subject to multiple discounting rules (ie, the highest valued APC is paid at a rate of 100%, and subsequent APCs are paid at a rate of 50%). (Note: even though CPT code 31637 is an add-on code and is exempt from multiple discounting for physician payment, for HOPPS purposes it is subject to multiple discounting rules.) The bottom line for this hypothetical situation is that using two metallic stents results in a $207 loss for the facility; using silicone stents provides a net reimbursement of $1,343.33. So, while it can be argued that the payments for the stents, whether metallic or silicone, are bundled into the APC rate, it is clear that this HOPPS methodology has created a huge economic incentive for using silicone stents (or a disincentive for using metallic stents, however you choose to look at it). It is also worthwhile to note that inflatable balloons and guidewires, which are frequently used in conjunction with metallic stents, are bundled items (Table 5).
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Because of the nature of interventional bronchoscopy, we recommend that all facilities performing complicated central airway interventions create a cost center. This cost center allows full capture of not only the facility fees for the bronchoscopy but, by creating a unique patient ID account, other benefits such as ordered laboratory tests, radiologic examinations, and changes in referral patterns can be tracked.
Conclusion
Improved reimbursement for bronchoscopic stent placement is required. These procedures are high-risk, are complex, and are performed in patients with poor physiologic reserve, severe illnesses, and multisystem medical problems. The current financial reimbursements almost present a deterrent to airway stenting on the professional billing side. Facility reimbursement rules provide a disincentive for the use of metallic stenting and outpatient procedures. Currently, the best business model is a hospital-funded or health system-funded regional center of excellence using a cost-center approach to evaluate the real return on investment.
Acknowledgements
The authors are indebted to Rosemary Brekke and MaryLisa Tippett from Princeton Reimbursement Group for their invaluable advice and careful review of the manuscript.
Footnotes
Abbreviations: APC = ambulatory payment classification; CAO = central airway obstruction; CCI = National Correct Coding Initiative; CMS = Centers for Medicare and Medicaid Services; CPT = current procedural terminology; DRG = diagnosis-related group; EBUS = endobronchial ultrasound; EM = evaluation and management; HOPPS = Hospital Outpatient Prospective Payment System; MPFS = Medicare physician fee schedule; PE = practice expense; POS = place of service; RVU = relative value unit
This article is not intended as a complete tutorial on physician payment and makes no guarantee of coverage or payment. Payers or their local branches may have their own coding and reimbursement requirements and policies. Information is time sensitive. Before filing any claims, readers should verify current requirements and policies with the payer.
Dr. Lund and Mr. Garland have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Dr. Ernst or his employer has received unrestricted educational grants for research and CME activities from Boston Scientific, Alveolus, Bryan Corp, and Novatech.
Received for publication March 22, 2006. Accepted for publication September 25, 2006.
References
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