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Endobronchial Ultrasound
Accepted Manuscript Endobronchial Ultrasound: Clinical Uses and Professional Reimbursements Thomas R. Gildea, MD MS FACP FCCP, Katina Nicolacakis, MD FCCP PII:
S0012-3692(16)49003-3
DOI:
10.1016/j.chest.2016.05.009
Reference:
CHEST 469
To appear in:
CHEST
Received Date: 25 January 2016 Revised Date:
26 April 2016
Accepted Date: 5 May 2016
Please cite this article as: Gildea TR, Nicolacakis K, Endobronchial Ultrasound: Clinical Uses and Professional Reimbursements, CHEST (2016), doi: 10.1016/j.chest.2016.05.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Endobronchial Ultrasound: Clinical Uses and Professional Reimbursements
Thomas R. Gildea MD MS FACP FCCP
Thomas R. Gildea MD MS FACP FCCP Head, Section of Bronchoscopy Respiratory Institute
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Katina Nicolacakis MD FCCP
Department of Pulmonary, Allergy and Critical Care Medicine & Transplant Center
9500 Euclid Ave Desk M2-141
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Cleveland, OH 44195
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Cleveland Clinic
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Key Words: Bronchoscopy, EBUS, TBNA, professional Reimbursement, CPT Word Count: 2789
Conflict of Interest: Dr. Gildea has presented to CMS on behalf of Olympus regarding technical reimbursement Conflict of Interest: Dr. Nicolacakis is the Chair of American Thoracic Society Clinical Practice Committee and an ATS Advisor to the AMA Relative Value Scale Update Committee (RUC).
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Abstract: Endobronchial Ultrasound (EBUS) has become an invaluable tool in the diagnosis of patients with a variety of thoracic abnormalities. The majority of EBUS procedures are used to diagnose and stage mediastinal and hilar abnormalities as well as peripheral pulmonary targets with a probe based
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technology. Nearly 1000 articles have been written about its use and utility. New Current Procedural Terminology (CPT®) codes have been introduced in 2016 to better capture the work and clinical use associated with the various types of EBUS procedures. The existing 31620 code has been deleted and replaced by three new codes, 31652, 31653 and 31654. These new codes have been through the
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valuation process and the new rule for reimbursement has been active since January 1st 2016 and with National Correct Coding Initiative (NCCI) correction as of April 1, 2016. The impact of these new codes
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will result in a net reduction in professional and technical reimbursement. This article describes the
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current use of EBUS and explains the current codes and professional reimbursement.
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Introduction: Endobronchial Ultrasound (EBUS) technology has been a major advancement in pulmonary medicine
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and broadly expanded the role of bronchoscopy and interventional pulmonology primarily in the realm of lung cancer. There are currently 2 different EBUS technologies in clinical practice and a third rarely used technique. The most commonly used by far, is the linear convex EBUS bronchoscope designed for directing transbronchial needle aspiration (TBNA) of central hilar and mediastinal structures. This has 2 basic applications- the diagnosis of abnormal mediastinal or hilar structures and the systematic
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mediastinal interrogation for staging lung cancer. Radial EBUS is a catheter directed probe used for localizing lung lesions beyond the central airways, and is often used as an add-on to peripheral
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diagnostic techniques or an adjunct to techniques such as navigational bronchoscopy, ultrathin bronchoscopy and other guided techniques. The third, but rarely used technique is the balloon probe EBUS catheter which is used for assessment of transmural airway wall structures typically for ascertainment of tumor invasion of the airway wall structures. The balloon probe was the original technique that was used to describe and value the 31620 EBUS code where the balloon probe was placed against the endobronchial wall where an adjacent lymph node was suspected and then the
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position confirmed. The probe was removed, and then conventional TBNA was performed in the general location when the balloon EBUS had confirmed location. The advent of the linear EBUS bronchoscope with its ability to perform real-time visualization of the TBNA needle entering the target made the balloon probe obsolete for this purpose. This article will review the basic clinical application of EBUS and
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the impact of the change in the CPT codes in 2016. See Table 1 for CPT code descriptions.
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As of this writing there are 976 articles about EBUS in PubMed. These describe many aspects of the procedure from clinical utility; novel techniques and unusual disease entities biopsied or managed; initial experiences, comparative effectiveness and randomized clinical trials. To suggest that this technology has led to a prodigious advancement in the realm of Bronchology cannot be understated. A recent article entitled “Endobronchial Ultrasound Changed the World of Lung Cancer Patients: A 11-Year Institutional Experience” is just one example of this evidence.1 We have made mention of 2 distinct clinical uses of linear EBUS. Although there is a potential for overlap between staging and diagnostic EBUS in many cases of lung cancer it should be recognized there are
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very different work times, and effort associated with each. There are several articles that describe staging techniques and demonstrate comparisons versus mediastinoscopy including randomized, controlled trials 2.
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Table 2 lists several clinical examples for diagnostic EBUS. Diagnostic EBUS is typically used in cases where formal mediastinal interrogation is not required. This occurs frequently in individuals with malignancies other than lung cancer where mediastinal lymph nodes demonstrate metastatic spread. Breast cancer, colon cancer, renal cancer, melanoma and others
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are well known. Diagnostic EBUS is also used in cases where primary lung cancer is already suspected and additionally, the mediastinal lymph nodes are the easiest and safest to biopsy and provide tissue confirmation and molecular markers as well but further staging is not required 3, 4. There are also cases
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where EBUS may aid in the diagnosis of benign conditions such as sarcoidosis5 or bronchogenic cysts that require a focused sampling of a limited number of mediastinal or hilar structures. Staging EBUS is a systematic interrogation of all mediastinal and hilar lymph nodes and sampling with a lower threshold for lymph node size, and performed in order of sampling the highest nodal station first. The ACCP Quality (AQuIRE) registry provided us some interesting data about Interventional Pulmonology
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practice use of EBUS in a small group of centers with relatively high volumes 6. In this article the number of sites of TBNA sampling was recorded. A single site was biopsied 32.3% of the time and 2 sites 30.6%, 3 sites- 23.1%, 4 sites 8.7%, 5 sites- 4.2% and 6 sites 1.1%. The main point being that EBUS in larger centers is a multistage procedure the majority of the time. It is also notable in this study that lymph
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nodes sampled were smaller than 10mm 42.9% of time. This demonstrates that this tool is not simply used for large mediastinal masses. EBUS has been shown to be a preferred first step in the initial diagnosis and staging of lung cancer 7-10.The use of EBUS technology has been associated with
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exceptional safety reporting a complication rate consistently less than 2% 6, 18.. The radial EBUS probe is used as an add-on to standard bronchoscopy techniques. As a stand-alone tool with a guide sheath it has been shown to be associated with a similar yield as navigational bronchoscopy, but as an adjunct to navigational bronchoscopy it has an even higher yield11, 12. Radial EBUS is rarely used alone. From a technical standpoint, once the lesion is located with peripheral EBUS the radial probe can be removed and the guide sheath or other catheter is left behind to perform biopsies. All standard biopsy tools including TBNA needles, cytology brushes, transbronchial biopsy forceps and perhaps even new instruments can be used with a sufficient catheter. The use of an
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aspiration catheter is also reported in the literature and appears to be associated with a higher yield than even transbronchial biopsies 13, 14. The use of the balloon probe EBUS is now relatively rare. Although it was the original technique described for mediastinal biopsies 15 it still has a limited role for
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assessing wall structures16, 17. The use of the peripheral radial EBUS instrument uses the ZZZ “add-on” code 31654. Category I CPT ZZZ “add-on” codes cannot stand alone, and must always be used with another base bronchoscopy code. In the case of Radial EBUS, the time and effort associated with the use of the probe is in addition to a bronchoscopy code for a specific diagnostic procedure. Those typically used include, Bronchoscopy
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with transbronchial lung biopsy 31628, Bronchoscopy with transbronchial needle aspirate biopsy 31629, and Bronchoscopy with brushings or protected brushings 31623 etc.
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Professional Reimbursement:
A complete review of bronchoscopy coding and billing is beyond the scope of this article and there are several better sources of this available from American College of Chest Physicians. An update is available in the ACCP Coding for Chest Medicine 2016 book 18, which includes a section on EBUS. The changes in the codes for 2016 have been proposed to try to capture the change in technology and the
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clinical utility of the EBUS techniques. As is typical with this process, work on updating the codes began several years prior, in 2014, and required several iterations of the phrasing and description of the “typical” procedures, which led to a CPT Code proposal to the CPT Editorial Board. Once the new codes were approved, this then led to a formal AMA RUC (American Medical Association Relative Value Scale
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Update Committee) survey for valuation of the codes. This process is arduous and requires that randomly selected individuals that perform the procedure with sufficient volume first agree to participate in the survey, and then understand how the survey instrument works so they can accurately
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complete the survey AND be able to compare the work of EBUS to other similar procedural codes. There are several articles about this process and the “work” associated with pre, intra and post-service procedure work and other valuations19-23. These survey results are submitted via professional societies to the AMA RUC. The AMA then submits its recommendations to CMS (Centers for Medicare Services) for consideration of both professional; Hospital /ASC (Ambulatory Service Centers) and Office based reimbursement based on a host of data submitted including practice expense ascertainments. Once reviewed, CMS publishes a proposed rule for public comment then after consultation with an advisory board and period of public comment the final rule goes into effect on the January 1st of the next calendar year.
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The new, final rule for EBUS was published November 16th, 2015 in the Federal Register24. This is an extensive document that describes in considerable detail all of the changes expected in the next year with regard to the Medicare physician fee schedule and other revisions. The introduction and background sections are helpful to understanding the terminology used and the basic concepts of how
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the various billing and coding sections are used in different environments. There are also point-by-point responses to the public comments. One of the most basic concepts to understand is how payments are calculated. Payment is based on RVUs (Relative Value Units) that is dependent on several other factors. This includes physician work, practice expense, and professional liability insurance costs. All these
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factors are adjusted by the Geographic Practice Cost Index (GPCI), which accounts for local cost
differences. The cost of medical care in Manhattan NY is far higher than Clyde, Ohio as an example. This RVU is then multiplied by the universal conversion factor which is set annually by CMS and this
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determines the total reimbursement. When there is a non-government payer the payment may be based on contractual agreements and less easy to understand. Nevertheless, from a physician perspective the work RVUs are universal, thus are valuable to discuss New Code Changes:
In January 2016 there were changes to the CPT codes that describe the different applications of EBUS
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and also correct language relative to the location of biopsies to more precisely describe the service and intent. Prior to 2016 EBUS (31620) was a ZZZ add-on code thus was required to be billed with another basic bronchoscopy code such as a TBNA (31629). Performing an additional TBNA could be coded as
limitation.
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(36133) but it was often limited to this one additional add-on code. This may be a payer or carrier level
Now, because it was very difficult to separate the work associated with EBUS from the TBNA the new
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codes merged the two procedures and changed the terminology to reflect mediastinal and hilar stations or structures rather than lobes. Also, because it was difficult to ascertain the incremental work of each different node or station sampled an an arbitrary cut off between 2 or less or 3 or more
stations is used. Again this was based on the fact that the AQuIRE registry noted that the majority of cases were performed with 2 or fewer stations sampled in 62.9% of the cases 6. The RVUs were based on the survey results and by committee approval of the AMA RUC, who then submitted recommendations to CMS. The changes and terminology are listed in Table 1.
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Codes are re-surveyed regularly by federal law, or when practice evolves and a change in procedure is demonstrated. This may lead to either an expansion of existing codes or the development of new codes as is the case here. The net impact of the new codes will be as follows: The RVUs base code for bronchoscopy 31622 will not change. The TBNA code (31629) will drop from 4.09 to 4.00 RVU’s and the
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new codes will bundle the EBUS with the TBNA and the add-on TBNA locations.
Prior to 2016 a bronchoscopy with EBUS with TBNA of 1 station would be billed using the following codes: 31629 [4.09RVUs] (TBNA is the base code is highest value) then the add-on code for EBUS 31620 [1.40RVUs] would be added. The total RVUs would be the addition of the base code and the add-on
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code thus equal to 5.49 total RVUs. In 2016 this would be coded as 31652 with total RVUs of 4.71.
The performance of a systematic mediastinal staging in 2015 we would have billed 31629+31620+31633
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and this equals a total of 4.09+1.40+1.32= 6.81 RVUs. In 2016 this will simply be 31653, and thus only 5.21 RVUs.
The use of the peripheral EBUS code 31654 is the same as the existing 31620 code from an RVU standpoint (1.40) and it is also a (ZZZ) add-on code. Again, as an add-on code, the full value of this code is allowed when reported with another appropriate bronchoscopy code. In most cases this is one of the
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CPT codes for a bronchoscopy with biopsy. In our clinical practice a TBNA used in the lung periphery is coded with the CPT 31629 then the add-on 31654 is added for an EBUS directed guide sheath sampling. Then additional codes for protected brush (31623) and transbronchial biopsy (31628) can be added subject to the multiple endoscopy rule. Since 31629 TBNA is NOT allowed to be coded with either 31652
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or 31653 but may be used in the peripheral lung separately and the other associated biopsy codes (31623-31633), appropriate documentation must support the use of the 31629 in another area separate from the EBUS TBNA in the same session. To be clear, the 31629 TBNA code will still be appropriate for
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conventional TBNA when EBUS is not used in the mediastinum or hila. The multiple endoscopy rule is used when coding for multiple endoscopy procedures performed in a single session either in an office or a facility setting. Our discussion in regards to RVUs has been and will continue to be limited to the professional reimbursement for physician work in a facility. Using the example above of the peripheral lesion which is sampled with TBNA (31629) using peripheral EBUS (ZZZ31654) as well as transbronchial biopsy (31628) and protected brushings (31623), the highest complexity code is coded first, followed by the lower complexity codes. The reimbursement and RVUs are calculated by starting with the highest complexity procedure or in this case the 31629 (RVU 4.00) and
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then adding each additional procedure less the base bronchoscopy code, which is the 31622 (2.78 RVUs). The basis for the multiple endoscopy rule is that the payment for most complex bronchoscopy codes already includes the payment for the base bronchoscopy code. So in our example you would add the 31628 (3.80 RVUs) minus 31622(2.78 RVUs) and add the 31623(2.88) minus 31622(2.78). You would
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also add the ZZZ-31654 (1.40 RVUs). The total calculation would therefore be as follows: 4.00 + (3.802.78) + (2.88-2.78) + 1.40 for a total of 6.42 RVUs of physician work. Remember the ZZZ add-on codes are added and reimbursed at full value. The Medicare reimbursement for this physician work in a facility with slight geographic variation, would be approximately $206.00 + $45.86 + $2.50 + $69.86 =
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$324.22.
If we used the AQuIRE registry the split would be that 62% of EBUS cases would change to the 31652
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code and the remainder would use the 31653 code. If we used hypothetical 100 patients based on AQuIRE the net loss would be as described in Table 3. A very rough estimate of expected total dollars is based on RVUs X conversion factor. This is a rough estimate since there are geographical adjustments and differences in the CMS rates based on location in the US. The base conversion factor is a constant for CMS and is adjusted annually for budget neutrality. This year the base conversion factor will be $35.8043. This is net reduction from 2015 $35.9335. The reduction of RVUs and would lead to a net
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reduction of approximately $5400 in professional fees based on this hypothetical cohort of 100 patients. In the first quarter of 2016 an error in the implementation of the CMS/NCCI (National Correct Coding Initiative) edits was noted. The error resulted in a limitation such that some appropriate code pairs were causing correctly coded claims to be rejected, denied or improperly (under) paid. ACCP and ATS alerted
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the NCCI contractor and the correction will have been corrected by 4/1/2016. Professional societies had suggested holding claims until this date or plan to adjudicate EBUS claims that have already been
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submitted between January 1st and March 30th 2016 since the correction will be retroactive to January 1st 2016.
Conclusion:
The Role of EBUS in pulmonary medicine has no doubt been a major improvement in the assessment of patients with mediastinal and hilar abnormalities and particularly those with suspected lung cancer as a very safe and effective minimally invasive procedure. Almost 1000 articles in PubMed have shown evidence of repeatedly high clinical value in many areas of thoracic disease. The procedure although enjoying high clinical utility has recently been revalued and has new codes to describe the techniques in
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the current form and standard of care. CMS is now going to reimburse less based on adjusted RVUs. The magnitude of the change is a reduction of professional reimbursement and a savings to CMS. Additional data about the effort, time and costs associated bronchoscopy is still needed and will prove to be very useful to help inform issues of professional and technical reimbursement. Education of
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potential CPT/RUC survey participants to accurately complete these surveys is crucial for our
professional societies to help us deliver new technologies to our patients when they prove to be
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clinically valuable.
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References 1 Chen CH, Liao WC, Wu BR et al. Endobronchial Ultrasound Changed the World of Lung Cancer Patients: A 11-Year Institutional Experience. PLoS One. 2015;10(11):e0142336.
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2 Yasufuku K, Pierre A, Darling G et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393-400.e1.
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3 Tanner NT, Watson P, Boylan A et al. Utilizing endobronchial ultrasound with fine-needle aspiration to obtain tissue for molecular analysis: a single-center experience. J Bronchology Interv Pulmonol. 2011;18(4):317-321. 4 Yarmus L, Akulian J, Gilbert C et al. Optimizing endobronchial ultrasound for molecular analysis. How many passes are needed? Ann Am Thorac Soc. 2013;10(6):636-643.
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5 Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial Ultrasound Guided TBNA vs. Conventional TBNA in the diagnosis of sarcoidosis. Chest. 2014; 6 Eapen GA, Shah AM, Lei X et al. Complications, consequences, and practice patterns of endobronchial ultrasound-guided transbronchial needle aspiration: Results of the AQuIRE registry. Chest. 2013;143(4):1044-1053.
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7 Almeida FA, Casal RF, Jimenez CA et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782. 8 De Leyn P, Dooms C, Kuzdzal J et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg. 2014;45(5):787-798.
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9 Silvestri GA, Gonzalez AV, Jantz MA et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e211S-50S.
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10 Almeida FA. Bronchoscopy and endobronchial ultrasound for diagnosis and staging of lung cancer. Cleve Clin J Med. 2012;79 Electronic Suppl 1:eS11-6. 11 Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. 2012;142(2):385-393. 12 Eberhardt R, Anantham D, Ernst A, Feller-Kopman D, Herth F. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176(1):36-41. 13 Eberhardt R, Morgan RK, Ernst A, Beyer T, Herth FJ. Comparison of suction catheter versus forceps biopsy for sampling of solitary pulmonary nodules guided by electromagnetic navigational bronchoscopy. Respiration. 2010;79(1):54-60.
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14 Franke KJ, Nilius G, Ruhle KH. Transbronchial catheter aspiration compared to forceps biopsy in the diagnosis of peripheral lung cancer. Eur J Med Res. 2009;14(1):13-17. 15 Herth F, Becker HD, Manegold C, Drings P. Endobronchial ultrasound (EBUS)--assessment of a new diagnostic tool in bronchoscopy for staging of lung cancer. Onkologie. 2001;24(2):151-154.
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16 Shaw TJ, Wakely SL, Peebles CR et al. Endobronchial ultrasound to assess airway wall thickening: validation in vitro and in vivo. Eur Respir J. 2004;23(6):813-817. 17 Baba M, Sekine Y, Suzuki M et al. Correlation between endobronchial ultrasonography (EBUS) images and histologic findings in normal and tumor-invaded bronchial wall. Lung Cancer. 2002;35(1):65-71.
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18 Manaker S, Phhlig C, Merlino D. In: Coding for Chest Medicine 2016, 17th Ed. Glenview, IL: American College of Chest Physicians; 2016
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19 Becker ER, Dunn D, Hsiao WC. Relative cost differences among physicians' specialty practices. JAMA. 1988;260(16):2397-2402. 20 Braun P, Yntema DB, Dunn D et al. Cross-specialty linkage of resource-based relative value scales. Linking specialties by services and procedures of equal work. JAMA. 1988;260(16):2390-2396. 21 Dunn D, Hsiao WC, Ketcham TR, Braun P. A method for estimating the preservice and postservice work of physicians' services. JAMA. 1988;260(16):2371-2378.
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22 Hsiao WC, Braun P, Dunn D, Becker ER. Resource-based relative values. An overview. JAMA. 1988;260(16):2347-2353. 23 Hsiao WC, Yntema DB, Braun P, Dunn D, Spencer C. Measurement and analysis of intraservice work. JAMA. 1988;260(16):2361-2370.
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24 Centers for Medicare & Medicaid Services (CMS), HHS. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016. Final rule with comment period. Fed Regist. 2015;80(220):70885-71386.
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Table 1 Selected 2015 and 2016 CPT codes 2015 Codes
Description
Work RVU
31622
Bronchoscopy, flexible or rigid, including fluoroscopic guidance, when performed; diagnostic, with cell washing Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) (List separately in addition to code for primary procedure[s])
2.78
Will be deleted
1.40
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31620
31629
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)
31633
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure)
1.32
2016 Codes
Description
Work RVU
31622
Bronchoscopy, flexible or rigid, including fluoroscopic guidance, when performed; diagnostic, with cell washing Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)
2.78
31652
Bronchoscopy with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures
4.71
31653
Bronchoscopy with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures
5.21
Bronchoscopy with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s])
1.40
31654
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31629
4.09
4.00
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Table 2 Clinical Examples of EBUS Procedures
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31653
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Staging EBUS- start from contrallateral hilum and sample all lymph nodes over 5mm. Final procedure was associated with sampling of the left hilum 11L, the Left paratrachea 4L, subcarina 7, right paratrachea 4R, and right hilum 11R. Navigational Bronchoscopy with TBNA, cytology brush, transbronchial biopsy with radial EBUS localized the lesion
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Patient with a 2cm growing, PET avid, LUL lesion with history of breast cancer and an obvious bronchus sign but behind the scapula and in a pocket of bulla
Type of EBUS Code Diagnostic, typically and BAL and 31652, 31628, 31624 EBUS TBNA of 2 lymph nodes, +/Transbronchial biopsies Diagnostic EBUS of right hilar 31652 mass
31629, 31628, 31623, 31627, 31654
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Clinical Case Patient with bilateral hilar and mediastinal adenopathy, cough and rashes. Suspect Sarcoidosis Patient with right hilar mass with long smoking history and brain metastases. Patient with 4CM right upper lobe mass already diagnosed with lung cancer via CT-FNA but ipsilateral and subcarinal PET avid adenopathy. History of histoplasmosis and mediastinal adenopathy
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Table 3 Estimates of RVU changes with hypothetical 100 patients based on AQuIRE registry
23 9 4 1
Total 2015 RVUS
2016 Codes/ RVUs
31629 +31620 31629+3163 3+31620 31629+3163 3+31620 31629+3163 3+31620 31629+3163 3+31620 31629+3163 3+31620
5.49
175.68
31652
4.71
6.81
211.11
31652
4.71
6.81
156.63
31653
5.21
6.81
61.29
31653
6.81
27.24
31653
6.81
6.81
100
Total 2016 RVUs
31653
638.76
Diff
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31
2015 Codes/RVUs
150.72
24.96
146.01
65.1
119.83
36.8
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One Station Two Stations Three Stations Four Stations Five Stations Six Stations
Hypot hetica l N=100 32
5.21
46.89
14.4
5.21
20.84
6.4
5.21
1.6
489.5
149.26
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Stations sampled
5.21
Table 4 Estimate of Reimbursement changes 2015 to 2016 based on Table 3 hypothetical cohort.
RVU X Conversion Factor
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638.76 X 35.9335 489.5 X 35.8043
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2015 Reimbursement 2016 Reimbursement
Total Revenue (unadjusted for CGI) $22,952.88 $17,526.20 4,5426.68 net loss
S0012-3692(16)49003-3
DOI:
10.1016/j.chest.2016.05.009
Reference:
CHEST 469
To appear in:
CHEST
Received Date: 25 January 2016 Revised Date:
26 April 2016
Accepted Date: 5 May 2016
Please cite this article as: Gildea TR, Nicolacakis K, Endobronchial Ultrasound: Clinical Uses and Professional Reimbursements, CHEST (2016), doi: 10.1016/j.chest.2016.05.009. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Endobronchial Ultrasound: Clinical Uses and Professional Reimbursements
Thomas R. Gildea MD MS FACP FCCP
Thomas R. Gildea MD MS FACP FCCP Head, Section of Bronchoscopy Respiratory Institute
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Katina Nicolacakis MD FCCP
Department of Pulmonary, Allergy and Critical Care Medicine & Transplant Center
9500 Euclid Ave Desk M2-141
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Cleveland, OH 44195
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Cleveland Clinic
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Key Words: Bronchoscopy, EBUS, TBNA, professional Reimbursement, CPT Word Count: 2789
Conflict of Interest: Dr. Gildea has presented to CMS on behalf of Olympus regarding technical reimbursement Conflict of Interest: Dr. Nicolacakis is the Chair of American Thoracic Society Clinical Practice Committee and an ATS Advisor to the AMA Relative Value Scale Update Committee (RUC).
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Abstract: Endobronchial Ultrasound (EBUS) has become an invaluable tool in the diagnosis of patients with a variety of thoracic abnormalities. The majority of EBUS procedures are used to diagnose and stage mediastinal and hilar abnormalities as well as peripheral pulmonary targets with a probe based
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technology. Nearly 1000 articles have been written about its use and utility. New Current Procedural Terminology (CPT®) codes have been introduced in 2016 to better capture the work and clinical use associated with the various types of EBUS procedures. The existing 31620 code has been deleted and replaced by three new codes, 31652, 31653 and 31654. These new codes have been through the
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valuation process and the new rule for reimbursement has been active since January 1st 2016 and with National Correct Coding Initiative (NCCI) correction as of April 1, 2016. The impact of these new codes
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will result in a net reduction in professional and technical reimbursement. This article describes the
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current use of EBUS and explains the current codes and professional reimbursement.
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Introduction: Endobronchial Ultrasound (EBUS) technology has been a major advancement in pulmonary medicine
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and broadly expanded the role of bronchoscopy and interventional pulmonology primarily in the realm of lung cancer. There are currently 2 different EBUS technologies in clinical practice and a third rarely used technique. The most commonly used by far, is the linear convex EBUS bronchoscope designed for directing transbronchial needle aspiration (TBNA) of central hilar and mediastinal structures. This has 2 basic applications- the diagnosis of abnormal mediastinal or hilar structures and the systematic
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mediastinal interrogation for staging lung cancer. Radial EBUS is a catheter directed probe used for localizing lung lesions beyond the central airways, and is often used as an add-on to peripheral
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diagnostic techniques or an adjunct to techniques such as navigational bronchoscopy, ultrathin bronchoscopy and other guided techniques. The third, but rarely used technique is the balloon probe EBUS catheter which is used for assessment of transmural airway wall structures typically for ascertainment of tumor invasion of the airway wall structures. The balloon probe was the original technique that was used to describe and value the 31620 EBUS code where the balloon probe was placed against the endobronchial wall where an adjacent lymph node was suspected and then the
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position confirmed. The probe was removed, and then conventional TBNA was performed in the general location when the balloon EBUS had confirmed location. The advent of the linear EBUS bronchoscope with its ability to perform real-time visualization of the TBNA needle entering the target made the balloon probe obsolete for this purpose. This article will review the basic clinical application of EBUS and
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the impact of the change in the CPT codes in 2016. See Table 1 for CPT code descriptions.
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As of this writing there are 976 articles about EBUS in PubMed. These describe many aspects of the procedure from clinical utility; novel techniques and unusual disease entities biopsied or managed; initial experiences, comparative effectiveness and randomized clinical trials. To suggest that this technology has led to a prodigious advancement in the realm of Bronchology cannot be understated. A recent article entitled “Endobronchial Ultrasound Changed the World of Lung Cancer Patients: A 11-Year Institutional Experience” is just one example of this evidence.1 We have made mention of 2 distinct clinical uses of linear EBUS. Although there is a potential for overlap between staging and diagnostic EBUS in many cases of lung cancer it should be recognized there are
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very different work times, and effort associated with each. There are several articles that describe staging techniques and demonstrate comparisons versus mediastinoscopy including randomized, controlled trials 2.
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Table 2 lists several clinical examples for diagnostic EBUS. Diagnostic EBUS is typically used in cases where formal mediastinal interrogation is not required. This occurs frequently in individuals with malignancies other than lung cancer where mediastinal lymph nodes demonstrate metastatic spread. Breast cancer, colon cancer, renal cancer, melanoma and others
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are well known. Diagnostic EBUS is also used in cases where primary lung cancer is already suspected and additionally, the mediastinal lymph nodes are the easiest and safest to biopsy and provide tissue confirmation and molecular markers as well but further staging is not required 3, 4. There are also cases
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where EBUS may aid in the diagnosis of benign conditions such as sarcoidosis5 or bronchogenic cysts that require a focused sampling of a limited number of mediastinal or hilar structures. Staging EBUS is a systematic interrogation of all mediastinal and hilar lymph nodes and sampling with a lower threshold for lymph node size, and performed in order of sampling the highest nodal station first. The ACCP Quality (AQuIRE) registry provided us some interesting data about Interventional Pulmonology
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practice use of EBUS in a small group of centers with relatively high volumes 6. In this article the number of sites of TBNA sampling was recorded. A single site was biopsied 32.3% of the time and 2 sites 30.6%, 3 sites- 23.1%, 4 sites 8.7%, 5 sites- 4.2% and 6 sites 1.1%. The main point being that EBUS in larger centers is a multistage procedure the majority of the time. It is also notable in this study that lymph
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nodes sampled were smaller than 10mm 42.9% of time. This demonstrates that this tool is not simply used for large mediastinal masses. EBUS has been shown to be a preferred first step in the initial diagnosis and staging of lung cancer 7-10.The use of EBUS technology has been associated with
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exceptional safety reporting a complication rate consistently less than 2% 6, 18.. The radial EBUS probe is used as an add-on to standard bronchoscopy techniques. As a stand-alone tool with a guide sheath it has been shown to be associated with a similar yield as navigational bronchoscopy, but as an adjunct to navigational bronchoscopy it has an even higher yield11, 12. Radial EBUS is rarely used alone. From a technical standpoint, once the lesion is located with peripheral EBUS the radial probe can be removed and the guide sheath or other catheter is left behind to perform biopsies. All standard biopsy tools including TBNA needles, cytology brushes, transbronchial biopsy forceps and perhaps even new instruments can be used with a sufficient catheter. The use of an
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aspiration catheter is also reported in the literature and appears to be associated with a higher yield than even transbronchial biopsies 13, 14. The use of the balloon probe EBUS is now relatively rare. Although it was the original technique described for mediastinal biopsies 15 it still has a limited role for
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assessing wall structures16, 17. The use of the peripheral radial EBUS instrument uses the ZZZ “add-on” code 31654. Category I CPT ZZZ “add-on” codes cannot stand alone, and must always be used with another base bronchoscopy code. In the case of Radial EBUS, the time and effort associated with the use of the probe is in addition to a bronchoscopy code for a specific diagnostic procedure. Those typically used include, Bronchoscopy
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with transbronchial lung biopsy 31628, Bronchoscopy with transbronchial needle aspirate biopsy 31629, and Bronchoscopy with brushings or protected brushings 31623 etc.
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Professional Reimbursement:
A complete review of bronchoscopy coding and billing is beyond the scope of this article and there are several better sources of this available from American College of Chest Physicians. An update is available in the ACCP Coding for Chest Medicine 2016 book 18, which includes a section on EBUS. The changes in the codes for 2016 have been proposed to try to capture the change in technology and the
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clinical utility of the EBUS techniques. As is typical with this process, work on updating the codes began several years prior, in 2014, and required several iterations of the phrasing and description of the “typical” procedures, which led to a CPT Code proposal to the CPT Editorial Board. Once the new codes were approved, this then led to a formal AMA RUC (American Medical Association Relative Value Scale
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Update Committee) survey for valuation of the codes. This process is arduous and requires that randomly selected individuals that perform the procedure with sufficient volume first agree to participate in the survey, and then understand how the survey instrument works so they can accurately
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complete the survey AND be able to compare the work of EBUS to other similar procedural codes. There are several articles about this process and the “work” associated with pre, intra and post-service procedure work and other valuations19-23. These survey results are submitted via professional societies to the AMA RUC. The AMA then submits its recommendations to CMS (Centers for Medicare Services) for consideration of both professional; Hospital /ASC (Ambulatory Service Centers) and Office based reimbursement based on a host of data submitted including practice expense ascertainments. Once reviewed, CMS publishes a proposed rule for public comment then after consultation with an advisory board and period of public comment the final rule goes into effect on the January 1st of the next calendar year.
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The new, final rule for EBUS was published November 16th, 2015 in the Federal Register24. This is an extensive document that describes in considerable detail all of the changes expected in the next year with regard to the Medicare physician fee schedule and other revisions. The introduction and background sections are helpful to understanding the terminology used and the basic concepts of how
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the various billing and coding sections are used in different environments. There are also point-by-point responses to the public comments. One of the most basic concepts to understand is how payments are calculated. Payment is based on RVUs (Relative Value Units) that is dependent on several other factors. This includes physician work, practice expense, and professional liability insurance costs. All these
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factors are adjusted by the Geographic Practice Cost Index (GPCI), which accounts for local cost
differences. The cost of medical care in Manhattan NY is far higher than Clyde, Ohio as an example. This RVU is then multiplied by the universal conversion factor which is set annually by CMS and this
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determines the total reimbursement. When there is a non-government payer the payment may be based on contractual agreements and less easy to understand. Nevertheless, from a physician perspective the work RVUs are universal, thus are valuable to discuss New Code Changes:
In January 2016 there were changes to the CPT codes that describe the different applications of EBUS
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and also correct language relative to the location of biopsies to more precisely describe the service and intent. Prior to 2016 EBUS (31620) was a ZZZ add-on code thus was required to be billed with another basic bronchoscopy code such as a TBNA (31629). Performing an additional TBNA could be coded as
limitation.
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(36133) but it was often limited to this one additional add-on code. This may be a payer or carrier level
Now, because it was very difficult to separate the work associated with EBUS from the TBNA the new
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codes merged the two procedures and changed the terminology to reflect mediastinal and hilar stations or structures rather than lobes. Also, because it was difficult to ascertain the incremental work of each different node or station sampled an an arbitrary cut off between 2 or less or 3 or more
stations is used. Again this was based on the fact that the AQuIRE registry noted that the majority of cases were performed with 2 or fewer stations sampled in 62.9% of the cases 6. The RVUs were based on the survey results and by committee approval of the AMA RUC, who then submitted recommendations to CMS. The changes and terminology are listed in Table 1.
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Codes are re-surveyed regularly by federal law, or when practice evolves and a change in procedure is demonstrated. This may lead to either an expansion of existing codes or the development of new codes as is the case here. The net impact of the new codes will be as follows: The RVUs base code for bronchoscopy 31622 will not change. The TBNA code (31629) will drop from 4.09 to 4.00 RVU’s and the
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new codes will bundle the EBUS with the TBNA and the add-on TBNA locations.
Prior to 2016 a bronchoscopy with EBUS with TBNA of 1 station would be billed using the following codes: 31629 [4.09RVUs] (TBNA is the base code is highest value) then the add-on code for EBUS 31620 [1.40RVUs] would be added. The total RVUs would be the addition of the base code and the add-on
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code thus equal to 5.49 total RVUs. In 2016 this would be coded as 31652 with total RVUs of 4.71.
The performance of a systematic mediastinal staging in 2015 we would have billed 31629+31620+31633
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and this equals a total of 4.09+1.40+1.32= 6.81 RVUs. In 2016 this will simply be 31653, and thus only 5.21 RVUs.
The use of the peripheral EBUS code 31654 is the same as the existing 31620 code from an RVU standpoint (1.40) and it is also a (ZZZ) add-on code. Again, as an add-on code, the full value of this code is allowed when reported with another appropriate bronchoscopy code. In most cases this is one of the
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CPT codes for a bronchoscopy with biopsy. In our clinical practice a TBNA used in the lung periphery is coded with the CPT 31629 then the add-on 31654 is added for an EBUS directed guide sheath sampling. Then additional codes for protected brush (31623) and transbronchial biopsy (31628) can be added subject to the multiple endoscopy rule. Since 31629 TBNA is NOT allowed to be coded with either 31652
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or 31653 but may be used in the peripheral lung separately and the other associated biopsy codes (31623-31633), appropriate documentation must support the use of the 31629 in another area separate from the EBUS TBNA in the same session. To be clear, the 31629 TBNA code will still be appropriate for
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conventional TBNA when EBUS is not used in the mediastinum or hila. The multiple endoscopy rule is used when coding for multiple endoscopy procedures performed in a single session either in an office or a facility setting. Our discussion in regards to RVUs has been and will continue to be limited to the professional reimbursement for physician work in a facility. Using the example above of the peripheral lesion which is sampled with TBNA (31629) using peripheral EBUS (ZZZ31654) as well as transbronchial biopsy (31628) and protected brushings (31623), the highest complexity code is coded first, followed by the lower complexity codes. The reimbursement and RVUs are calculated by starting with the highest complexity procedure or in this case the 31629 (RVU 4.00) and
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then adding each additional procedure less the base bronchoscopy code, which is the 31622 (2.78 RVUs). The basis for the multiple endoscopy rule is that the payment for most complex bronchoscopy codes already includes the payment for the base bronchoscopy code. So in our example you would add the 31628 (3.80 RVUs) minus 31622(2.78 RVUs) and add the 31623(2.88) minus 31622(2.78). You would
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also add the ZZZ-31654 (1.40 RVUs). The total calculation would therefore be as follows: 4.00 + (3.802.78) + (2.88-2.78) + 1.40 for a total of 6.42 RVUs of physician work. Remember the ZZZ add-on codes are added and reimbursed at full value. The Medicare reimbursement for this physician work in a facility with slight geographic variation, would be approximately $206.00 + $45.86 + $2.50 + $69.86 =
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$324.22.
If we used the AQuIRE registry the split would be that 62% of EBUS cases would change to the 31652
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code and the remainder would use the 31653 code. If we used hypothetical 100 patients based on AQuIRE the net loss would be as described in Table 3. A very rough estimate of expected total dollars is based on RVUs X conversion factor. This is a rough estimate since there are geographical adjustments and differences in the CMS rates based on location in the US. The base conversion factor is a constant for CMS and is adjusted annually for budget neutrality. This year the base conversion factor will be $35.8043. This is net reduction from 2015 $35.9335. The reduction of RVUs and would lead to a net
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reduction of approximately $5400 in professional fees based on this hypothetical cohort of 100 patients. In the first quarter of 2016 an error in the implementation of the CMS/NCCI (National Correct Coding Initiative) edits was noted. The error resulted in a limitation such that some appropriate code pairs were causing correctly coded claims to be rejected, denied or improperly (under) paid. ACCP and ATS alerted
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the NCCI contractor and the correction will have been corrected by 4/1/2016. Professional societies had suggested holding claims until this date or plan to adjudicate EBUS claims that have already been
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submitted between January 1st and March 30th 2016 since the correction will be retroactive to January 1st 2016.
Conclusion:
The Role of EBUS in pulmonary medicine has no doubt been a major improvement in the assessment of patients with mediastinal and hilar abnormalities and particularly those with suspected lung cancer as a very safe and effective minimally invasive procedure. Almost 1000 articles in PubMed have shown evidence of repeatedly high clinical value in many areas of thoracic disease. The procedure although enjoying high clinical utility has recently been revalued and has new codes to describe the techniques in
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the current form and standard of care. CMS is now going to reimburse less based on adjusted RVUs. The magnitude of the change is a reduction of professional reimbursement and a savings to CMS. Additional data about the effort, time and costs associated bronchoscopy is still needed and will prove to be very useful to help inform issues of professional and technical reimbursement. Education of
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potential CPT/RUC survey participants to accurately complete these surveys is crucial for our
professional societies to help us deliver new technologies to our patients when they prove to be
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clinically valuable.
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References 1 Chen CH, Liao WC, Wu BR et al. Endobronchial Ultrasound Changed the World of Lung Cancer Patients: A 11-Year Institutional Experience. PLoS One. 2015;10(11):e0142336.
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2 Yasufuku K, Pierre A, Darling G et al. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg. 2011;142(6):1393-400.e1.
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3 Tanner NT, Watson P, Boylan A et al. Utilizing endobronchial ultrasound with fine-needle aspiration to obtain tissue for molecular analysis: a single-center experience. J Bronchology Interv Pulmonol. 2011;18(4):317-321. 4 Yarmus L, Akulian J, Gilbert C et al. Optimizing endobronchial ultrasound for molecular analysis. How many passes are needed? Ann Am Thorac Soc. 2013;10(6):636-643.
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5 Gupta D, Dadhwal DS, Agarwal R, Gupta N, Bal A, Aggarwal AN. Endobronchial Ultrasound Guided TBNA vs. Conventional TBNA in the diagnosis of sarcoidosis. Chest. 2014; 6 Eapen GA, Shah AM, Lei X et al. Complications, consequences, and practice patterns of endobronchial ultrasound-guided transbronchial needle aspiration: Results of the AQuIRE registry. Chest. 2013;143(4):1044-1053.
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7 Almeida FA, Casal RF, Jimenez CA et al. Quality gaps and comparative effectiveness in lung cancer staging: the impact of test sequencing on outcomes. Chest. 2013;144(6):1776-1782. 8 De Leyn P, Dooms C, Kuzdzal J et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg. 2014;45(5):787-798.
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9 Silvestri GA, Gonzalez AV, Jantz MA et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e211S-50S.
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10 Almeida FA. Bronchoscopy and endobronchial ultrasound for diagnosis and staging of lung cancer. Cleve Clin J Med. 2012;79 Electronic Suppl 1:eS11-6. 11 Wang Memoli JS, Nietert PJ, Silvestri GA. Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest. 2012;142(2):385-393. 12 Eberhardt R, Anantham D, Ernst A, Feller-Kopman D, Herth F. Multimodality bronchoscopic diagnosis of peripheral lung lesions: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176(1):36-41. 13 Eberhardt R, Morgan RK, Ernst A, Beyer T, Herth FJ. Comparison of suction catheter versus forceps biopsy for sampling of solitary pulmonary nodules guided by electromagnetic navigational bronchoscopy. Respiration. 2010;79(1):54-60.
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14 Franke KJ, Nilius G, Ruhle KH. Transbronchial catheter aspiration compared to forceps biopsy in the diagnosis of peripheral lung cancer. Eur J Med Res. 2009;14(1):13-17. 15 Herth F, Becker HD, Manegold C, Drings P. Endobronchial ultrasound (EBUS)--assessment of a new diagnostic tool in bronchoscopy for staging of lung cancer. Onkologie. 2001;24(2):151-154.
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16 Shaw TJ, Wakely SL, Peebles CR et al. Endobronchial ultrasound to assess airway wall thickening: validation in vitro and in vivo. Eur Respir J. 2004;23(6):813-817. 17 Baba M, Sekine Y, Suzuki M et al. Correlation between endobronchial ultrasonography (EBUS) images and histologic findings in normal and tumor-invaded bronchial wall. Lung Cancer. 2002;35(1):65-71.
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18 Manaker S, Phhlig C, Merlino D. In: Coding for Chest Medicine 2016, 17th Ed. Glenview, IL: American College of Chest Physicians; 2016
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19 Becker ER, Dunn D, Hsiao WC. Relative cost differences among physicians' specialty practices. JAMA. 1988;260(16):2397-2402. 20 Braun P, Yntema DB, Dunn D et al. Cross-specialty linkage of resource-based relative value scales. Linking specialties by services and procedures of equal work. JAMA. 1988;260(16):2390-2396. 21 Dunn D, Hsiao WC, Ketcham TR, Braun P. A method for estimating the preservice and postservice work of physicians' services. JAMA. 1988;260(16):2371-2378.
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22 Hsiao WC, Braun P, Dunn D, Becker ER. Resource-based relative values. An overview. JAMA. 1988;260(16):2347-2353. 23 Hsiao WC, Yntema DB, Braun P, Dunn D, Spencer C. Measurement and analysis of intraservice work. JAMA. 1988;260(16):2361-2370.
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24 Centers for Medicare & Medicaid Services (CMS), HHS. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016. Final rule with comment period. Fed Regist. 2015;80(220):70885-71386.
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Table 1 Selected 2015 and 2016 CPT codes 2015 Codes
Description
Work RVU
31622
Bronchoscopy, flexible or rigid, including fluoroscopic guidance, when performed; diagnostic, with cell washing Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) (List separately in addition to code for primary procedure[s])
2.78
Will be deleted
1.40
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31620
31629
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)
31633
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure)
1.32
2016 Codes
Description
Work RVU
31622
Bronchoscopy, flexible or rigid, including fluoroscopic guidance, when performed; diagnostic, with cell washing Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)
2.78
31652
Bronchoscopy with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures
4.71
31653
Bronchoscopy with endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures
5.21
Bronchoscopy with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s])
1.40
31654
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31629
4.09
4.00
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Table 2 Clinical Examples of EBUS Procedures
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31653
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Staging EBUS- start from contrallateral hilum and sample all lymph nodes over 5mm. Final procedure was associated with sampling of the left hilum 11L, the Left paratrachea 4L, subcarina 7, right paratrachea 4R, and right hilum 11R. Navigational Bronchoscopy with TBNA, cytology brush, transbronchial biopsy with radial EBUS localized the lesion
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Patient with a 2cm growing, PET avid, LUL lesion with history of breast cancer and an obvious bronchus sign but behind the scapula and in a pocket of bulla
Type of EBUS Code Diagnostic, typically and BAL and 31652, 31628, 31624 EBUS TBNA of 2 lymph nodes, +/Transbronchial biopsies Diagnostic EBUS of right hilar 31652 mass
31629, 31628, 31623, 31627, 31654
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Clinical Case Patient with bilateral hilar and mediastinal adenopathy, cough and rashes. Suspect Sarcoidosis Patient with right hilar mass with long smoking history and brain metastases. Patient with 4CM right upper lobe mass already diagnosed with lung cancer via CT-FNA but ipsilateral and subcarinal PET avid adenopathy. History of histoplasmosis and mediastinal adenopathy
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Table 3 Estimates of RVU changes with hypothetical 100 patients based on AQuIRE registry
23 9 4 1
Total 2015 RVUS
2016 Codes/ RVUs
31629 +31620 31629+3163 3+31620 31629+3163 3+31620 31629+3163 3+31620 31629+3163 3+31620 31629+3163 3+31620
5.49
175.68
31652
4.71
6.81
211.11
31652
4.71
6.81
156.63
31653
5.21
6.81
61.29
31653
6.81
27.24
31653
6.81
6.81
100
Total 2016 RVUs
31653
638.76
Diff
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31
2015 Codes/RVUs
150.72
24.96
146.01
65.1
119.83
36.8
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One Station Two Stations Three Stations Four Stations Five Stations Six Stations
Hypot hetica l N=100 32
5.21
46.89
14.4
5.21
20.84
6.4
5.21
1.6
489.5
149.26
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Stations sampled
5.21
Table 4 Estimate of Reimbursement changes 2015 to 2016 based on Table 3 hypothetical cohort.
RVU X Conversion Factor
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638.76 X 35.9335 489.5 X 35.8043
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2015 Reimbursement 2016 Reimbursement
Total Revenue (unadjusted for CGI) $22,952.88 $17,526.20 4,5426.68 net loss