In this joint Lumendi-ASGE Webinar, we focus on both reimbursement challenges and practical solutions for Endoscopic Submucosal Dissection (ESD) in mainstream practice.
Dr. Othman and ASGE Staff covered the following topics:
Establishing a sustainable complex endoscopic resection program
Navigating reimbursement of the physician fees for ESD procedures
Integrating an ESD practice within an RVU-based system
welcome the American Society for Gastrointestinal Endoscopy. Appreciate your participation in our newly branded Thursday night lights. Webinar serious. Tonight's event is entitled Reimbursement for Complex and Aske OPIC Reception. Navigating the Tortures Road. The discussion of this webinar will focus on how to establish a sustainable complex and this Coptic resection program and the current reimbursement off the physician components off SD and suggestions on how to fit is the practice in an RV. You bassist. My name is ready Hajkova, and I'll be the moderator for this presentation. Tonight's session is brought to you by the support of Loom nd, a global medical technology company that is committed to creating technologies that enable endoscopy is to perform at a higher level and minimize risk and recovery time for patients. SG greatly appreciates tremendous support tonight before we get started. Just a few housekeeping items. Quick disclaimer that the views and opinions expressed during tonight's webinar are those of the presenter and do not necessarily reflect the official policy or position on h G. Um, there also will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question box and the go to webinar panel on the right hand side of your screen. If you do not see the go to Webinar panel, please click on the white arrow on the orange box, located on the right hand side of your screen. Please note that this presentation is being recorded and will be posted within two business days on G I Leap SGS Online Learning Platform. You will have ongoing access to the recording in jelly as part of your registration. Now it is my pleasure to introduce our presenter for tonight's Dr Mohamed Othman. Doctor Othman is a board certified and fellowship trained advance and Das Copies. He is an associate professor of medicine, gastroenterology and hepatology section at Baylor College of Medicine and his chief of gastroenterology section at Baylor Sand Luke's Medical Center. That the Othman graduated from University of Mansoor of School of Medicine in Egypt and shortly after began his residency in an internal medicine at University of New Mexico School of Medicine, which was followed by a fellowship in gastroenterology and hepatology. Dr. Othman completed his advanced G I Fellowship at Mayo Clinic, Jackson Building Jackson in Florida following his fellowship in Mayo, Doctor Othman accepted a position as an assistant professor division of gastroenterology, Department of Internal Medicine at Paul L. Foster School of Medicine, Texas Tech in El Paso, Texas, until 2000 and 14 when he joined Baylor College of Medicine in Houston. Over the last 20 years, Dr Altman has been the recipient of various research grants and has been widely published in many peer reviewed scientific publications and book chapters and is a regular speaker on the academic circuit, both nationally and internationally. With so much experience, we are very fortunate to have Dr Rothman present tonight's WEBINAR and that will now hand the presentation over to Dr Altman. Well, thank you so much for this nice introduction. Ready. And I'm very excited to talk about new topic that A We usually talk about the technicality off the procedure. But today you are going to talk about actual building a program and establishing and E S D program in United States on part of establishing a program is to figure out how tohave reimbursement. Um, it is different when you do one procedure every three months. One complex pulled back to me every three months versus when When you do that in a daily basis or that's like maybe 40 or 50% of your practice I'm going to go through my experience and it's my personal experience had and how to build an SD program in the United States, including the building part. So before we talk about, um, the S D we want to talk about the e m. R in United States and M r is well established procedure. Um, it was started to be done used in United States before SD. And for that reason we have a dedicated cpt code for building for EMR. Although that code did not come tell maybe 2013 or 2014. So even the EMR code in United States and New Code, However, the different techniques of EMR either was cab without cab and with underwater without water. All of these are acceptable and published and in a way, become a mainstream in the United States. In fact, we have SG, of course, is dedicated for EMR. It's called semester classes for m R. That s G has been doing them and for years now was focused and improving the technique in United States of doing M r eso in comparison. If you look at the S d. That was my first publication. SD in 2011 was my mentor, Mike Wallace. And at that time e s the United States was not that common a time. There was very few center doing it. A few lesions starting only with gastric lesion or talking about hybrid techniques mainly which is m are part off. It s D and even for Kalanick lesion were thinking it is a little bit too much to do. Es de for Kalanick Legion at that time, this was our thinking. Um, jumping now, 10 years later, in 2021 e s t is gaining popularity. United States, I would say we have more than 15 SD referral center in United States on when I say referral center. I mean center who are doing at least 50 procedures or more annually and that number is increasing. This one I know off and I know people who are doing these numbers, I would tell you 34 years ago there were maybe four or five centers only, and the SG now have a sponsored training for SD called the Asian master, of course, and it is a great course. I took it personally in 2012 and two Sorry, 2013, which was the first class in 2014, and I would say that course is how I built my connection with the Asian Masters. How I end up going after that to Japan and China was through that course and through meeting people in that course and building this relationship, H g continue to do this course, and it is one of the most successful courses for teaching. Is the United States also? Yes, there's an area of planned expansion for every measure academic center. So in every place there is a need for somebody who can do complex fall victim ease and removing, uh, large lesions and also dealing with sub mucosal lesions. Um, although we don't have somebody dedicated for that in each center, I would envision the same, like what happened was endoscopic ultrasound will happen with CSD, and very soon we'll find dedicated, uh, personnel for SD in each academic center. So what's the downside? What's holding SD back in United States number one that we always have this debate between EMR and SD Why I will do is D if I can do EMR and the results sometimes comparable, but definitely there are certain lesion that you need to do es d four. But treasure we're doing m r es the at the end of the day and discover techniques are also competing with surgery. And that's one of the major things were senior trained in that laparoscopic surgeries for colon, uh, cases or colonial lesions are increasing. I'm gonna show slides about that. So there's always this debate why you do all of this. You can send the patient for surgery and get it done. Well, why you remove, adjust by endoscopy. We can do wedge resection and take care of it. And also we do not have enough data from the Western Endoscopy is showing the superiority of E S. D. So we have a lot of publication about M R. But most of the SD data is coming from Asia, particularly Japan and China. And when you try to present this data, United States, they will say Well, they have a different patient population. They have a different disease and maybe whatever applied to them or whatever successful there is not successful here. Reality is I would say it is the same. However, we have to prove it. We have to have our own data showing the superiority VSD, which we are in the process of doing now. So I wanna show the slide here which showed the annual incidence rates for the non malignant colorectal polyps and colorectal cancer surgeries in United States. What we're seeing here in the dotted line, that's a corrective cancer. You can see the rates off surgery are decreasing over the years. So what about the non malignant corrector polyps? Actually, they are increasing part of understanding. Reimbursement for SD is to understand this slide In United States, we have an Opry city epidemic. That obesity epidemic has many drawbacks. One off them. With that, many patient will develop colorectal polyps that would be larger and also at earlier age. So we heard about right now that the US task force would like Thio start screening colonoscopy at age of 40 because we have enough evidence that the rate of colon cancer are increasing in in patient who are 40 years old. Uh, between 40 to 50 and then in the other hand, because of obesity to when you try to do procedures for this patient, it is very hard to do the colonoscopy, let alone removing complex palate. So gastroenterologist will just send this patient for surgery, they said. We know what it took me half an hour to reach the coal in this patient is £350 on this palette is in a tough location behind the fold, a spare to send the patient for surgery. So now we're getting this trend that we have a sicker patient was larger polyps. And instead of investing in an endoscopic techniques to help them, most of this patient is going for laproscopic surgery. And what is the surgery? It is either write him or collect me or left him collect me, which is a major surgery. You almost removing half of the entire colon for Eponine Pallop. And although maybe some of you practicing and academic centers once you goto private practice, once you go to ah, smaller centuries, you'll find that it's totally acceptable that five centimeter, four centimeter parliament in the right side of the colon that's totally benign and cheaper adenoma would be treated with writeem collecting me. So in a way, if you think about why endoscopy is better for this lesion, if you look here from the health care system perspective, a surgery will cost at least $15,000 versus endoscopy $6000. And that's in Australia, United States. Not even it could be even more expensive. But that's an Australian study showing the cost of endoscopy and the one in green. Here is the cost of endoscopy, including anesthesia, and including that the patient will have another follow up industry. And that's her cost of surgery. And, of course, that's huge difference. If we look at the actual endoscopic mortality based on physiological score and physiological score, the higher IT ISS, the sacred the patient and we compare. The actual endoscopic mortality was published data about protected surgical mortality you'll find in very sick patient. The one was liver disease. The one was chronic kidney disease who have physiological score above 15. You can see here is a surgical mortalities from increasing from 12% to 28% but the actual endoscopic mortality 0%. I want to stop here for a second and talk about why this happened. There is something about opening the pertain iam that stimulate a cascade off inflammatory reaction. So go into the opportunity. Um from the skin, in a way, is more traumatizing than dissecting the polyp on disk optically without causing perforation. And also, even if micro profession happened during the procedure, they are easily manageable on you're not exposing the patient with this intense inflammatory reaction. Eso basically it makes sense in Dusko is cheaper on endoscopy is actually safer on. In spite of that, the argument is hard because we're not able to make successful polytechnics program, which in this situation will be based around E. S. D. So how can you have a successful history program? You wanna address the needs of the population of interest so you cannot have an SD program for gastric cancer In a population that doesn't have gastric cancer, you're not addressing the needs of your population. Eso unless you are in a city that have large number off patient who are from Asian descent or Hispanic and you can discover gastric cancer early in the United States. Do me is D for gastric cancer is very rare. Also, you need to provide value that's superior to other modality. So you want to prove that the SD is much better than surgery, which we just talked about right now and also you wanted to compliment already existing programs you have. So if you have a successful and discovered program for doing colon resection, that would be something complemented. If you have a large practice off EMR in United States, you can convert your EMR practice into SD So we'll talk a little bit about the Kalanick e S d in United States and we can see here when we talk about SD. We're talking about the sub mucosal layer and we're basically focusing in removing the entire lesion in one piece. That's an examples here, off lesions that are removed by SDI and the first slide and I chose this picture is just to show the complexity of this procedure. So the first slide we can see here we're using an assisted device for civilization. We're using another device for grasping, and we're using a specialized knife to dissect the lesion, and you can see here the muscle layer under it, and you're working in a space like 2 to 3 millimeter to remove that lesion picture on the right side. Here. You can see a very flat power removed by M. R. Before and you have this white process in the middle, and it's very hard. You can imagine. If you're doing EMR. That's very hard to do. M r for religion like that down here, that's appendix. And that's another tubular adenoma in the appendix. And you can see here that the lesion is taking the appendices orifice and it's actually closing the appendix and there's past coming out. It's a complex region. In the past, something like that would be sent for surgery. On Dhere is an example off the end result of removing this lesion with the SD. You will have the polyp completely removed in one piece, and you are goingto have all the margin around it. Very clear and very nice. So these are examples a lesion letter spreading tumor granular, non granular, specifically and granular. We want removed them with the S D flat lesion byproduct region like this one here or a pencil orifice lesions. So there is a need for this In United States. We see a lot of this lesions and will continue to see more of it. And as we saw from this picture to have to do an SD process, you need a lot of devices. You need an electro surgical unit. Injection devices resection devices such as snares and knives, ablation, devices him Stasis devices, and you also sometimes destabilizing devices and tissue opposition devices like claps and other. So if you think about this, it is really costing. But if you also think about the cost of surgery on the cost of going to the O. R. Room to do right or left him a collective me and you see the amount of devices they're using, you will discover that although are using all these devices, it's still cheaper than going for surgery. So how do you go about that? How can you, you know, build a program with all of this? And for this particular for STS, We see here you will need a lot of clips. Clips are not that cheap, and that's why we need to develop more and more of these cheaper options. And I know some of the companies now are coming with cheaper clips. Clips were very expensive in the past and now we can find them in a cheaper prices. Stabilizing device is also important for chronic es de eso. Decreasing the cost is important, but also convincing our administrators and the health care system by the tell tale e s d is important. Um, that's you're comparing EMR versus CSD and we show here that procedure time for ASD is longer. There's another thing. So it's not only that I'm using too many devices, you are spending longer time in your room. So, as we can see here is 100 minute for E S D versus 29 minutes for M R. But if you look at their current straight for SD, it is 0.9% versus 12% for M R. That's a huge difference in terms of their parents. And if one of these recurrence lead to cancer, then SD is really saving, um, the health care system and the patient in this situation. So it's longer time. It requires more procedure and also does not have a CBT code so established this program was reimbursement is even harder. Add to that that yourself you have to invest in yourself to learn SD so I'm going to tell you that my experience is that I started my interest in E S D in 2011. I start doing animal labs between 2011 to 2014 and I did basic labs and advanced animal labs like life, animals and courses. And later on I started doing SD in 2014. My practice is not pick up to become a really is the practice until 2017. Now, by 2021 I like last year 2020 I did more than 300 g s d a year but reached that number. It took me around nine years off starting interests, which was in 2011. So you have to have a basic reconditioned. You have to be in a referral sinner have experienced an EMR. You don't have to be a senior. Endoscopy is, but you cannot start out of fellowship interested in learning us and learning a recipe. But also in the meantime, learning SD and E s d require focus. And if you're not feeling comfortable ercp and you're chasing each and every year CBR seeing then you'll not have time to learn that. So it's not about being a senior in hospitals, but I would say 23 years out of fellowship whom you're not that worried about your ear CB skill or from the beginning, you're just focused on complex Paul victories that they do in Japan. They just either go for Ercp route or for Paul Paektu, Mr Out, and they even divide the SD routes into upper and lower. Then after that, you have to make structural decision. And what I mean by that you're going to spend two hours, three hours in the room. The worst thing you can ever do is to plan your first is the case and you do it in, um, assuming it will be finished in one hour. And I spent three hours and everybody knocking on your door because they have another patient. After that, you have to plan it very well. You have to have a least half on our have at least 23 hours for the first case, and you have to communicate that with your system that you are still in the planning stage. Otherwise, somebody may write a complaint about you to the hospital, and that's happened to me at the beginning and they sent her to the CEO saying Dr Hoffman, he spent at least three hours doing and easily so basically, you have to explain to them that this is not an easy D, and that is a SD. And once you reach to 40 or 50 case now will be very comfortable. Now we start. Look for your outcomes. And what are your outcomes? You wanna look at your r zero section rate? You wanna look at your curative resection rate on you want to achieve our zero section rate off at least 90% curative resection rate dependent selection, but between 70 to 80% is important. Eso These are the steps of learning, so it's a complex procedure. Take a long time and you have to invest in yourself for a long time. And after that you have to build all the surrounding in order to ensure good reimbursement. And the first thing is excellent in dusky V team. Then you have to have supporting hospital administration and you have to educate the physicians in the communities. Remember this gastroenterologists who are sending the patient for surgeon. They will be the one who are sending you the cases in order for them to be convinced you have to talk to them, send them for sure. Send them pictures, make up it's in your website or even just show them pictures of the legion. Tell them you see that's one legion removed. If you have a patient like that who you think can go for surgery, I can save your patient surgery. Also, you have to have a good relationship with the surgical team. Explained to them that in you may have lesion that people refer to you that they could be not be removed by industry, and we'll send it to them also. We need them for backup. Complications happen. So in the US, Cuba team is extremely important. That specter of my industrial team at Baylor's and looks and I owe them, ah, lot of my success. But there is something important about technician and nurses. You have to limit your SD to at least three teen. I would say maximum 3 to 4 teams and I will tell you and see you time they come. They're going to come and tell you we have to train everyone because everybody has to be cross training and cross training is something big in the United States. Everybody has to be cross trained and people like to say this word. It doesn't work for SD, so your answer would be the following. Cross training is great, but STS an outpatient procedure. I will only do this procedure when I'm planning it. I understand that some of the staff may be off training. 2 to 3 texts are what we need. You don't need to train all the text in the unit and tell them not every physician are doing this procedure to. So as long as gastroenterologists are supper specializing, our technician and nurses will be sub specializing too. Can I start training two or three after that? If you want to expand, that's fine, but do not do. Each procedure was different person who they do not understand the electro surgical unit and don't know how to deal with the devices because they'll stress you out in your beginning of your experience and knowing this energy setting is important. And when you are so busy and you're asking for the coagulation grasp er, you may forget to tell your assistant please switch to soft calculation so because you are in a hurry. You want to control the bleeding. So him knowing that and him knowing how to switch the setting for you is very important or her, and to train him or her. It doesn't require only one case. It required that they share you and be part of that journey on. The same will happen for anesthesia team. You have to encourage them toe help you and encourage them to do general anesthesia, especially for right sided. Chronic legion. Andi Also, you teach them to follow the peak and respiratory pressure and see what the peak Inspectorate pressure at the beginning, what it will happen at the end. Until then, tell me what's going on. If the peak in splitter brush increase, that's important for me because this one you have tension, new abdomen, a. Knowing all this stuff is important and teaching goes there will be helping toe have the successful team then Supporting hospital administration is a tough part, and it depends on where you were, because the argument for SD on how the hospital can make a good reimbursement for es de depending how you will spend it at the end of the day, Um, they make money from surgery to. So if you go to your private practice hospital and tell them I have this awesome techniques that will help my patient and I'm going produce all the corrective surgery in the hospital and the I'm going to do half of their practice, then you don't like a discussion like that. It's better not to talk this way. It is better to focus and referral batter. Better to tell them that you know this patient will never come to our system. But because we are offering something unique and something non invasive, they are coming to our system. It's better to tell them that maybe the other hospital next to us offering that technique, and if we don't offer it, our patient will go for this non invasive route, and it is always nice to tell them, and some of these patients are referred to us. They actually may need surgery, and we'll send them for surgery. And I remember when I started and I came to Baylor and I was doing SD and start doing SD for high grade dysplasia and early esophageal cancer and the chief of cardiothoracic surgery the time make me. And he was very upset and he was one of the old school surgeon. And he told me high grade dysplasia should be treated by surgery on a self ejecta. Me and you better make sure that this patient are not getting their parents. And actually, that was good because it made me very careful. It made me have a good database and follow up in this patient. But guess what? Our number off a self eject to me doubled after I start doing SD because we will get some referrals that we think they are suitable for SD. But actually they end up going for surgery. They end up staying in the system later on for other things and for cities can. So there is always down the stream revenue from that. If you are working in another system, something like Kaiser, something like close network system. When the insurance owned by the system, then the cost saving is very important. Then when you tell them I'm going to save the system by doing SD, they will be excited about June it. But also be careful because in this network large network system, they will also have to assign certain people to do it, and it will be hard to prove why you are the one who will do it and not other one. And if you are in a smaller hospital, it may be harder to convince him because you will say, refer it to the major hospital, but focusing and cost saving in a system that's large network system. That's very good focusing and referral pattern in a private hospital, small hospital will be the winning argument. And, of course, if you are in a major academic center, then focusing in the US news ranking and being competitive in academia and publication will be another thing. And if you work with your chief and now you're chief asking you, you wanna do SD and how can you justify doing one case in 23 hours? You have to explain to him that that's how we're gonna be competitive and it is a period of time and I'm gonna get better. And in a way you will have to convince him that by doing that they are getting better. So as you can see here, it is multiple argument for multiple people, and you have to know who you are talking, too, because although all of us are interested and better outcomes for our patients, when it comes to how healthcare system work in United States, there is a lot of other consideration. And as a physician's, we have to be aware of it. And there is no health care system or no way of running the health care system. That would be, I would say, 100% culture. There is always consideration either cost consideration, either new innovation and techniques and how you consider doing them versus established techniques. So although this is annoying as a physician, we have to deal with it. We have to be comfortable dealing with it, and we shouldn't be upset. You know, at the end of the day, we should be proud that we're helping our patient and doing something good for them. So the billing process, how can you get reimbursement? If you just do the cases, you will find out that you're gonna have a good amount of rejection. So I learned after a while that if you are in a system that suspicious specifically our view based system and you told them, I'm doing a procedure that's not having a CBT code. They're going to use something called They have a reference book and they look at the unlisted code and they see that the unlisted code equivalent six Our view This how it is right now weighs in university practices. If you're gonna do Kalanick es de or s officially is there for six our view. That's very bad. That's even Listen, Ercp, you cannot justify that. So in order to justify it, they may tell them You know what? I am generating more money from this procedure. But in order generate more money, you have to make sure that the insurance will pay for it and for insurance have to pay for it. You have to go through this process that I'm going to explain to you right now. Number one. You have to write in every patient. I do. I write a letter off medical necessity. That letter is prepared if it is esophageal adenocarcinoma different than colon polyp on the letter will say the following patient blah blah, blah as this condition. The standard treatment by surgery is this. We're doing a SD because it does this and this and that, and that's cost saving for the insurance. I write that in the letter of medical necessity and we explained everything about the ASD in the letter and then we send the documentation of the medical record with it, and we also send additional data about the SD efficacy. And the one that I suggest that you guys use is that a G A clinical updates It was published in 2019 on Is showing the indication of the A S D and people respect clinical practice updates. It is we don't have guidelines yet for years the United States, but that's as close as it can get toe guidelines, which is the A G a clinical practice of it about SDF 2019. I'm going to show it at the end to my discussion, So I send them that and it's very hard to argue with clinical practice updates then what I'm saying right now is what I do in my practice, and I want to stress again that that's not the opinion of the off the SG. That's what I do for my practice and it's just a suggestion for you. I use generic code and this unlisted code that I'm using for 3499 for esophagus for 3999 stomach on 45399 for colon. And then I bought the regular Adrian colonoscopy code. Then you will have to pathway. If you're going to Medicare. You cannot do anything. You just will send all this stuff. But you cannot ask for pre authorization predetermination. You do the case and you send all this documentation to them again. But if you have private insurance, then I submit for something called voluntary pre determination request. So the insurance company, you will tell you just do the procedure and we'll talk after. And you told them? Nope. I don't wanna go through this round. I don't even get pre authorization. I want to get predetermination request. So there's a planetary predetermination request is that it means that you are telling them I want 100% reassurance from you that once I do, this procedure is going to be bait for the problem was doing voluntary determination request that it takes at least between 15 to 30 days. Andi, if you're doing Kalanick powers mostly behind, this would be good if you're doing it's a facial cancer. You can just expedite to try it a way to get it in the 15 days, but it's not gonna be done next day. It's not gonna be done even within a week. The minimum is two weeks. So when you do this bluntly with determination, you're gonna end up with two results. Either the except to do the case on they tell you are approved, then you schedule it or they will say we rejected and you can go for peer to peer. And in this situation, I do the peer to peer with the physician, and I would tell you most of the time they will accept it. So you would ask me why I would go through this painful route off doing all of this. And the reason is, if I really just do this procedure was pre authorization without getting predetermination, I may get 50% rejection rate and there will be no evidence of how much money was in rate because I am doing the economic SD for 12 our views or 14 our views on that, based on how much this procedure is paying for and when we built were built by the hours. So I will write in my note. I spent 100 minutes. I spent any 80 minute doing that and we try to build with this unlisted code 2 to 3 times the rate off EMR. So at the end of the day, you're gonna be getting the equivalent money. Like if you look at how much you get from us on you look at how much you get from SD procedure. We'll find that the equivalence around 12 to 14 our views on this What I get from my procedure was then my system, based on my history of collection on how I built a good history collection, is by using that system that I will only do the procedure that are approved for predetermination. Obviously, if you are still at the training stage and you're trying to find one or two lesions to do, that's fine. You don't have to do that. But once you have 50% of your practice, this patient you cannot afford doing patient who are not approved for the procedure eso what I'm showing you right now. If data from 163 patients insurance claim that done it better. Uh, get this data was so hard. It's almost was like an act of Congress to get this data from Baylor. I was able to get the physician reimbursement data on the condition is that when we talk about insurance, we're gonna love all private insurance under one name because you cannot specifically discussed the details off each contract that you have with other companies. So I'm not going to use names like Blue Cross Blue Shield or you are United Healthcare. We're going to use the word private insurance and also going to use the word government insurance to refer to Medicare and Medicaid and everything A Z you can see here that's for esophageal SD. We charge around 2839 and it's the ranges between 1400 to 5 8500. And that's what's my billing department, based on my note asked for. Our main payment rate is around 886 for a soft gel ASD and the range between as low as 121 and as high as 4500. So this could happen to and If you divide that by how much you've spent time working, you will find that the main payment per hour for its official LSD in my practice is $471. Actually, it's not bad. It's not great, but it's not bad. It will allow you to have a sustainable practice for gastric. And what LSD The payments? Slightly higher 3026 mean payment here or to ask for 3000 and mean payment 700. But if you look at the colorectal Es de, which a majority of my practice for E. S D, you'll find that our reimbursement physician reimbursement component is 1325 and the range the lowest is 55. Most likely, you know what type of insurance will be that on the highest was 3500 and a Z. You can see here mean payment for our significantly higher 755. Um, in my practice, I do maybe 60 to 70% this correctly S d. As a result of this, And if you are in a system that very savy and Baylor cultural medicine are so savvy, they collect all the information about how many patient You see, how many patients you do, how much collection you have, How many our views and they came up with this formula, if you're going to do is officially s d, we're going to give you nine our views. If you're gonna do Kalanick es de, it will be between it will be 12.5 are few or 13 our view. So based on their collection, they figure out that colorectal e s desire and the reason is the code for the colonoscopy slightly higher anyway than esophageal. But that should be guide for you that if you really do predetermination and you only do approved cases, that's what will get. And in spite of that, we had also some cases of denial. As you can see here, there's a range of denial on this. The range of denial, the number here is the number what we asked for, um, you look at if you divided the insurance by government versus prices. But private, you'll find that for all SD, the main payment is 900 or $5 on for private is 1100. But still, even in private insurance, there's huge variation, and the reason is we don't have a listed code. But in spite of that private insurance overall bay better than middle like government insurance around 2 $300. And if you standards like that per hour, because it's very important to know how long it take me. Because if you are getting paid $900 per procedure but you're spending eight hours doing it, then you are paid getting bit by our $100. But if you are fast enough and your main payment per hour would be higher and we can see here the main payment per hour for my procedures around 426 or government insurance 660 for private insurance and what I'm showing you guys, is this a really data on this actual practice on my practice? So if we look here, that's how the payment based on time and you can think in one hours if you're doing to colonoscopies, probably are going to do the same. If you are so fast and doing through colonoscopy, you're gonna make much more money. But anyways, if you are in the business of doing SD, you just want to make sure you get by because he is. The reimbursement is not that high yet in United States. So what is the rate of denial? Claim denials around 25% in spite off what I'm doing. But that was initially at the beginning. After that gets better and there's no difference between government versus private insurance or no difference based on SD location for what you get denied, it's just some reason they get denied and this very interesting and a lot of time when patient get denied, it is a process problem. So we asked for Predetermination. We thought we had it, but we did not have it. And most of the cases. But you have 25% deny rate and still that, in my opinion, was very high. So if you ask me, what are you getting reimbursed for? EMR. And that's here's the range between 100 065 29 was I mean off 250 or $260. So still for E. S d. I'm getting 2 to 3 times the EMR But when I'm building for E S d. I am building three times EMR so I'm trying to achieve that. If you are a surgeon and doing open collecting me, it will be between $1300 to 2000. And for lab collie, not big difference. Almost the same. So you will see here that still physician reimbursement for surgery as much higher although sometimes is to spend the same time. So what is the road ahead? We need more perspective data from the United States. This data will convince the fire Bayer tohave respect SD and have it at least in their less. But also we need to have the cpt code and very soon, hopefully we'll hear about that on I think our societies are working that reaching out to a G and S G toe on corporate SD in their management algorithm and guidelines are important. That's why we got into Asia. Convince him to have practice update for SD and I think it made a huge difference when that one got published also convincing our society to look on work on SD code which I know they're working. SG is doing a great job with that Onda also making prospective trials comparing lab collie versus CSD on I know This could be a sensitive trial, but we need this type of trial in United States. That's an example off the clinical practice abate. So far, we have two of them. First one about utility VSD and T one B esophageal cancer on the other one about the Asia Institute in Discovered is the United States. That's one is more common, I recommend added it for all your predetermination package. It will help with it. And if you send it any for any appeared to here and you told them, Please refer to this page and you'll find that that's what our society recommend. It's very hard for them. Toe argue with you. I would like to thank you and we'll open the discussion now for any questions. Thank you, Dr Altman, for that excellent presentation and for sharing your experience with the building process and, uh, and all the importance of data greatly appreciated that, um, the audience is ready with with questions for you. But first I just wanted to remind everyone the questions can be submitted by using the question box, and they go to Webinar panel on the right hand side of your screen. And if you do not see that Goto our panel, Please click on the white arrow on the orange box located on the right hand side of your screen. Um, our first question. I know you mentioned that there is a learning curve. Yes, you learning curve, if we have any. Any fellows that are in the call today Do you have any Any advice for them at all? Yes. So for fellow who are in fellows are interested in training at SD, I would say, um, it may take more than one year. So if you are going for an advance and dusk, we fellowship, I don't think within one year you will be able to master U. S A. R c B and es de, but definitely can have exposure for SD. And you can start doing animal labs for the first few years. If you ask me how many hours you should spend doing animals, I would say minimum off 20 hours in animal labs. After that, you may start going from X plan to life animals or, if you are in a program that you can assist, uh, normal in a in life cases that would be even better just take the journey a little bit by little bit and slow. The worst thing you can do as a journey that you come out of filled ship. You are in your first job in your first year and you do a procedure and you end up with a major complication and people established a certain reputation about you, which is not true. So for someone who's coming out of fellowship, I would say focus and improving your skill. Focus in getting very good in EMR. Also attend as many courses off SD as you can. Once you are known. Once people know about you, you have been there for six months. At least then you can start venturing out and try to do something out of ordinary. I wouldn't recommend coming out of culture by the way and start practicing SD unless you spent one year of dedicated training. Just re is the which we do not have yet in the United States. Excellent. Thank you. Um, the other question is regarding the building process and your you shared your experience where you write a letter on Ben. You explain what ASD is, and along with the letter you send the medical records and also the data with it. Um, And then you also mentioned that if authorization is needed, then you submit the voluntary predetermination request. Um, is that a difference between that and a prior authorization? Yes. Oh, yeah. That's a very important question. So prior authorization. It's more. It's almost like something you do before you do. Any procedure was Bible with any private insurance. You request their authorization. Andi Prior authorization is almost like a clerical thing. Usually the nurse or the office, Claire will look at the code and approve it. But predetermination, you are telling them I would like a physician off someone to look at this procedure and determined that it is needed for the patient. So pre authorization. You are authorizing this procedure based on a CBT code predetermination. You're saying I'm using unlisted code. I even the like. If you get a pre authorization, it's not guarantee that you're gonna get paid if you have a predetermination. Most of the time, that's approved case you're going to get paid for that one. And most of my denial came when I only had pre authorization, but no predetermination. Okay, the predetermination letter Does their work on Lee with with private institution are publicas? Well, yeah. So for public, you cannot do any of that. So if you work with Medicare, you cannot submit pre authorization. You cannot submit predetermination. You can submit everything after you do the procedure. So if it is a private insurance, you can ask for voluntary predetermination. If it is insurance like Medicare, you cannot do any of that. You just do the procedure and hope that it will be accepted. Surprisingly Medicare. They obey, they just pay less. But they do pay for these procedures. Okay, the does adding the modifier code 22 to the code you use making a difference in term of reimbursement at all. Yes, that's a good question. So modifier 22 is modifier for specialized service or service that took longer than anticipated and modifier 22. You can add it to any code or any cpt code I usually use. Modify a 22 with m R. Or sometimes if you're going to do something like hybrid s DNA. Um are you can put modifier 22 with the hybrid technique having said that, modifier 22 requires documentation off. Why you chose that? Codes? You can say, for example, there waas extensive fi process in the sub mucosa, which required that I spent 100 minute dissecting this lesion or giving the complex of the lesion and its location. I had to reserve into using that specialized device or chill it to that. So that language has to be there in the report to support the modifier 22. So just adding modifier 22 was a standard template would not be enough. Yeah, And then if if you use a unlisted code, that's it, okay. Or does it usually trigger a pre authorization letter or that are has to be a predetermination? So most of the time, it could be the authorization, but a lot of time. What happened that once used unlisted code, You're going out of the norm. So the clerk who are approving it, he was he's not gonna approve it. So if you, for example, for the same region use the cpt code that's there like a Marco, it will just pass right away. Once you put unlisted code, he will have a hard to stop. He cannot approve it, so he'll send it to the physician. Then the physician will review it. So instead of going every time through that and waiting for them to telling me that I just from the beginning say I'm submitting it for predetermination. I'm bypassing the first step them that makes sense. And the voluntary predetermination request you mentioned, it takes usually 15 to 30 days. Is there any way to expedite that that process at all? Yeah, And I have one case in case of severe emergency. You can tell them and request toe expedited. And you can request that quick peer to peer review. I had that done one time, but most of the time, unless you really have a strong reason that why you want to do it fast, you just have to wait. And there's also a better that when you work a lot with a certain private insurance, you know your name, they know you, they know you are doing that and they will start to understand what you're doing. And you will do like 1 to 2 to three peer to be review. And after that they know they know that you are the guy who always go in and fight for this. And one time I had a patient that I told them, You know what? I'm going to let CNN know that you are not approving. There's anyone the patient to go for under serious surgery and got to another high doctor. And by the way, if you got rejected in the premium peer to peer, you can always ask for something called a specialty. Appear to be here. So because however, talk to you could be a general practitioner, you may not be against in challenges, so you can say no. I need a specialty appear to be here. And usually if it goes to the gastroenterologist, hey will approve it. But unfortunately, this takes a lot of time and effort to do all the stuff. That's a that's a good way to to build relationships. Thank you for that. The during your presentation, you mentioned the toolbox for tissue reception. Um, any preference on on some of the tools that you use, uh, stabilizing devices or tissue that the opposition devices that you're you're using in your practice? Yes. So And I for chronic is d giving the lack of stability. There's two ways of doing it either do the bucket method, which is You go under the lesion or we can use stablizing devices. And the only one in the market is a double balloon device. And that double balloon device will help you to stabilize the lesion and perform e s d. I would say I would use it for 70 to 80% off my procedures for chronic SD. There's something I wanna talk back about the insurance issue. Um, sometimes and this happened to me here in Houston that there is a health care system that some of the physicians start referring cases to me for chronic ASD and that healthcare system. They own their insurance too. And the approach me and saying we found that some of our physician are sending you there colonic polyps that will otherwise would be sent for surgery. And they made it through the system to first consult me about these cases before they send it to their surgeon because they discovered that discussed saving on. I actually did not approach them about that. They just discovered it by themselves. So locally, you can do the same with your private insurance, too. If you can demonstrate to the private insurance that you have a cost saving. They will tell the patient to come to you. And I have the same happening in my pancreas practice that I will find patients showing up in my clinic. And I asked him who referred you and they say my insurance told me to come to you and you'll be surprised at the insurance. Now they keep track off the diagnosis you are seeing and they will say, For example, we are seeing you are in the 90 percentile or highest and 90 percentile and seeing Kalanick columns, Oracle, Asia or pancreatitis and one patient requires referral. They will ask him to go to U. S. O. In a way, building this relationship with insurance to will help. Wow! Any thoughts on having a bundled package for SD negotiated with private insurance to cover both physician and hospital feeds? Yes. So I tried that first for international patient because they also get some international patients for this procedure. In in Houston we get many of these patients and the problem was the packages that you need anesthesia to be important. You need pathology to being bored, and also you have to make it clear in the package that if complication happened and you're going to stay in the hospital, that would be outside the package, and that's a problem. Doing it for chronic is the I want successful doing that for screening colonoscopy. So I created for our international patient. A package for screening colonoscopy when we tried to do it for chronic is the My hospital was very reluctant, giving that once you are saying a package people expect, like is the hospital stay like Let's say that chronic is the now even admit the patient for arms. Is this part of it or not? Part of it and it became very hard. But I think once we apply for a code and we'll have a cpt code, I think having one night to stay will be part of that until be covered with it. Well, that's great. Uh, the and I appreciate you sharing some of the data. That is the reimbursement in the United States. Are are you seen or do you have an experience with data outside of United states, uh, for reimbursement for this type of procedures? Yes. So the best system for ASD would be the Japanese healthcare system and they have been doing STS now since 2002 and they mainly do it as a part of their effort to decrease gastric cancer. Eso es de reimbursement. There is very high and when you see that Japanese endoscopy is the only due to SD a day so the professor will do one and then go to his office in the afternoon to another one and we spend their time. Another doctor will be there doing another SD. So it is. We're reimbursed in Japan outside of Japan, I would say, even in China, it is still almost like China's government health care system. If you are in a big hospital, they will be doing large volume E s d smaller hospital. They will not have the SD at all in Europe. This is not clear yet. Like in England, they're barely developing their SDI programs. It's available in a few hospital there and the rest of Europe on other countries for like it's almost like patient has to pay for it. And in some of that Latin American countries, patient will pay for the knife cost before they start the procedures. So you will pay for the physician costs and also pay for the equipment costs before you do the procedures. So it's totally variable between country and another. Uh, do you think we'll get the cpt code soon? Yeah. We hope that the 2023 or 2024 well, we will have a code. I think we generated enough data now in the United States. Uh, Dr Peter Dragunov, I and another four or five physician. We just had our prospective registry off more than maybe 1000 s d done in the United States. We also have a prospective registry for chronic is D for procedure done using lamented double balloon device. And we have around 200 prospective patient done with that that would be published very soon. And so all once all this data come out, there will be enough evidence that we should have a CBT code in the United States. I feel I'm looking forward to that. Um, going back to the pre determination letter. Uh, do you typically mentioned the RV, you or the cost at all when you sent that? So when we send this latter letter to the insurance, we just say the word that this procedure will save the patient invasive surgery are alternative for this procedure is write him a collective I make sure or left him collecting or itself rejected me and I make sure that I put that in the letter. I don't say cost saving. I just write the alternative and only put the name of the surgery and become a little bit like too much. And by the way, the same happen with palm by Palm Per or my army. It used to be rejected all the time and United healthcare starting this October. They approved it on part of them, approving it, that many physician were complaining and I had a meeting. Was UnitedHealthcare like one year ago. And I told them It doesn't make any sense that you pushed patient tohave Hello, my army. While they can have industrial and we start to use even another my upper my army code, which is the CBT code and they say, just will approve it. But of course this is not the right code for it, but all of sudden, because of all the pressure In October of 2020 they start approving poem as a treatment because their guidelines were saying poem is experimental for S D. It's not like that because most of this patient have tumors and lesions on. They don't argue much with it. So in fact, I would say my peer to peer always go well for STDs sometime. It is harder for parole on my arm for a collision. Doctor. Doctor Altman, thank you so much for being being here with us tonight before we closed any. Any final thoughts that you like to leave the audience with? Yeah. I just want to tell them that in addition to learning the technics skill, just be aware that the process off doing SD involved working very well with your team with your hospital, the health care system and the insurance and also the referring physician on understanding all of this will enable you to have a successful yes D program. Dr. Altman, thank you so much for for sharing your experience here with with us tonight. Greatly appreciated. Ondas A final reminder. Please do Check is these calendar of events as we will continue to feature relevant sessions, tow our Thursday night light. Serious? Um also that that would like to take a moment to thank our corporate supporters for their contributions for making these events happened. Our next webinar will be next Thursday, January 21st at seven. PM presented by Dr Chris Thompson from Abe on endoscopic sleeve gastro plasticky. Um, in addition to our Thursday night webinars, we also plan to host events at various times to accommodate our audience around the world. Um, in closing Doctor Altman, thank you again for this excellent presentation with Brought, which was brought to you by loom nd for tremendous latest technological developments around the challenges facing health care providers and patients. Please do visit lamented dot com. Finally, I want to also thank you for your participation tonight. We hope this information has been useful to you on your practice and with this, uh, this concludes our our presentation. Thank you again.
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