You know, I would have thought as a course director I'd get to choose an exciting topic, but instead I get to give the talk right before lunch on the economics of endoscopic resection and how to make the finances work. So disclosure, I have no actual or perceived financial conflicts of interest to this content. And then a secondary disclosure, I do not have a finance background. So any questions that you guys have probably should go through your billing department or any local experts that you utilize. But this is kind of my two cents from my limited exposure to billing and then a limited review of the literature. I'm just going to be upfront with some of the resources that are available right now. So the Medicare Medicaid services, this is kind of their payment fee schedules, which help sort out what your CBT codes are. There are a lot of society resources. So if you go to any of our society websites, there are much better resources than what you're going to get from me today. But hopefully I can kind of put everything together for what we're doing with complex polypectomy. And then there's also really good industry resources. So industry is invested in trying to figure out how to get their market or their products to market. And so they have resources when you're thinking about bringing them on, working with them to figure out how to get those products paid for or incorporated in your practice can be helpful. I thought I would start with this paper. It came out not too long ago, but it kind of gives us a landscape of what's going on with colonoscopy and colon polyps across the US. So we do a lot of screening colonoscopies, four to 11% so higher than I just said, we'll have a large colorectal polyp greater than two centimeters. And we know that compared to surgical resection, endoscopic resection is associated with a reduced risk of adverse events and is more cost effective. But our guidelines also say that before surgical resections, we should send it to an advanced endoscopist for a repeat attempt. And the definition of advanced endoscopist is really up to you to decide. So do you have the comfort level to tackle a polyp? But in general, an attempt at endoscopic resection is still going to be more cost effective and I think a lot of previous presentations have shown why it's worth considering EMR or ESD for these lesions. We also know that surgery is going up. And the good news is there's fewer surgeries for malignancy. So hopefully we're finding things earlier, but there's a lot more surgery for non-malignant colon polyps. And you know, I think a lot of times then we take this data and we say, well, is it ESD versus EMR versus surgical resection? You've kind of seen all of us have that discussion right now. We don't really have surgeons here to put in their two cents, but I'd really encourage everybody to say, well, I don't know that it has to be a one is better than the other. And I think really it is what is the least invasive and most cost effective way of managing the polyp that's in front of you or the polyp that's getting referred to you. And so some of the assumptions I'm going to make for this talk are number one, EMR is established and effective tool for most laterally spreading granular polyps. ESD is hard to learn. It takes longer, particularly initially. It has higher complication rates and is definitely more resource intensive than EMR, but it's emerging as a procedure of choice for polyps with high risk features. And surgical resection has a higher complication rate and costs more than any endoscopic management we currently are using. Some polyps will still require surgery. And I think we've, you know, even our ESD folks agree on that. And some patients are not surgical candidates. So a lot of the referrals we get actually are from our surgical colleagues saying, do you guys think you can take out this like five centimeter mass? And you're like, I don't think we can do that. But there are patients with smaller lesions that get sent to surgery that really are in the purview of the endoscopist. And I think as you're thinking about whether you're going to expand your practice or what you're going to do with your practice, and how are you going to answer the question of what's the least invasive and most cost effective way of managing your patient's polyp is, you know, what does your community need? So are you walking into a community that already has four different people doing ESD with proficiency? Are you in a community where there is nobody doing ESD or complex polypectomy? Are you in a community where surgeons are doing a lot of endoscopy? You know, all these factor into what you're thinking about in terms of what skills you want to build and how much resource or hospital support you're going to have for what is a pretty resource intensive skill set. Once you kind of figure out what your need is, figure out how you're going to develop your skill set and how expensive it's going to be for you to get that skill set on board. And we'll talk about that on a few of the subsequent slides. And then how do you work within your community to grow the practice? So how do you work with your surgeons? How do you work with your hospital administration, your nurses and your tech team, as well as your referral base to kind of build that practice? And I think, as I think Sri mentioned earlier, if you don't innovate, you're really out of the game. And so really trying to figure out how you're going to continue innovation, bringing on new tools, new devices as they show improvement and discarding the ones that aren't working or discarding, you know, old practices that are maybe no longer appropriate. And then I think the last part is really important is how do you work with administration to support appropriate billing? And that's one of the harder parts. So again, what does your community need? Does it need more ESD? Does it need just better EMR? Or do you just need to have a bunch of people who are doing quality colonoscopy? And if the market's saturated, you may want to think twice about doing a lot of big investment into new techniques or devices. And as far as developing a skill set, you know, right now I would say most fellowships hopefully are preparing folks to take out, you know, relatively complex EMR. I would say, you know, one to two centimeters. I would think most people are coming out of fellowship training with that skill set. If not, there are, there's an ASG program with, you know, basics on EMR. There's also a lot of different industry supported training. So I think we talked earlier about FTR and working with Ovesco to bring you out to learn that device. Industry will also, you know, help you with endorotor hybrid APC if you decide to bring on those devices. ESD, we haven't talked too much exactly about what is the regimented training because there really is not a clear regimented training program in the US like there is in Japan. There is, you know, a few advanced fellowship training opportunities. But I think even talking with the folks who are doing ESD here, there's very few places that really feel like in that fourth year, you're getting your ERCP, you're getting your EUS, getting complex polypectomy, and you're facile enough to do ESD. And so really people are talking about a year on top of that or a separate year where you're not even really focusing on ERCP or EUS. You're really just working on that skill set for ESD. There are some advanced ESD skills taught through the ASGE. These courses are not so much designed to get you, you know, competent to do ESD, but really to get that initial exposure and say, all right, how are the devices, get your hands on a few of the scopes. I mean, you hopefully were able to get your hands on a few different devices at this program. Again, you're not going to walk out of here saying, gosh, I can do ESD. But it gives you that kind of foray into this is what it feels like and this is how hard it can be. And then there's both industry supported training programs and international courses. So a lot of the advanced endoscopists here have gone to places like India, Korea, or Japan to hone their skills. And you know, the hard thing is we don't really have great metrics in the West for how to bring on a practice. This is a paper from 2015 that's used a lot. You know, do you need to do 20 porcine procedures first? Do you need to do 20 rectal ESDs after you've done 20 porcine pigs? And then do you have to continue it with 25 ESDs in a year? You can imagine as you're building your referral base, if you do one ESD, then you don't get another referral for another three months, and then your skills lag, you really need to have that background of either animal model training or kind of trying to supplement your therapy. And so in this paper, you know, they kind of lay out the basic preconditions where you start with, you know, getting exposure, seeing what ESD is like, and then in the planning phase talking with your administration and saying, hey, I'm thinking about bringing this on as a practice, you know, are you supportive? And then taking that to the next level and doing the preparatory training, going to live courses, going to observe ESD experts, and then taking it from there, starting to do your cases. And really, think about it, it's like 80 cases before you become proficient. Talking with Muhammad Othman yesterday, his learning curve was somewhere around 280 before he felt comfortable. So you can only imagine if you're spending two to three hours on your first few cases, multiply that times 80, that's kind of the initial time investment that you should be thinking about in terms of bringing on something like ESD. And I think one of the things that we have seen in a few different instances is people who get into it have a terrible outcome on their first case and then never do it again. And so you've already done a lot of, you know, prep work. So really think about what you want to do and how are you going to set yourself up for success if you're going through this training process. One of the things as you're thinking about it are what do you need? So it's not just our typical stuff that we have in our ASC, where you have a cold snare, a hot snare, electrosurgical generator. You need to have both disposable devices and non-disposables. And so disposables, you know, you have to have your injection devices, your resection devices. You know, generally, you're going to have a full thickness resection device, a hot biopsy forceps, a few different knives. You need to have your hemostasis devices, a lot of which you saw today, and then closure devices. And some folks, not everybody, are using stabilizing platforms. And so you do need to have your hospital on board to bring these products in because just having them on the shelf, you know, some of them are going to expire. You're going to lose a little bit of the hospital's revenue that's going to be put into this equipment. Not only that, you have your non-disposables. So you have to have your electrical surgical unit. You need to have nurses and techs who know how to use it. And so I think that's the other thing. As you're thinking about building a training program, have one or two nurses, techs, maybe even three, because, you know, you want to have some degree of cross-training so that if that nurse is out sick on the day you're doing your ESD, you can bring somebody else in. But really working with the team, I mean, you've seen on a lot of the devices, the FTR, how much communication has to go in place between you talking with somebody to actuate that snare or just working with the suturing devices that you guys will be seeing next. If you don't have good, well-trained nurses, you're going to have a lot more struggles early on than if you're kind of training a team together. And then I think the one non-disposable that I've probably already talked too much about is time. And none of us have enough time. And so if you're saying, well, I'm going to cut out, you know, instead of doing six colonoscopies, I'm going to do one ESD case, that's a big time investment, particularly if that ESD case then goes to six hours and trying to figure out how you're going to incorporate that into your schedule. I think one of the hard things is when you're going to talk with the administration for a lot of things in GI, it really, I wouldn't frame it as you're taking business away from surgeons or there's going to be fewer downstream procedures. So even though for, you know, intuitively you want to do what's best for the patient, and of course it's best if they're getting less surgery and fewer procedures, but that's not necessarily what your hospitals are thinking. What they're seeing is, gosh, you're going to take away all our surgical revenue from lap hemis. Well, that doesn't make sense. Unless you're in a system like Kaiser or some other HMO where you can make that argument that you really are decreasing resources by putting them into GI. I think there is a downstream benefit to surgery. So you will have complications from your procedures that are going to need surgical help. And there are going to be unresectable polyps or polyps that you can't take out that you need to send on to the surgeons. One of the other things is appropriate use of hospital endoscopy space. So a lot of us have been pushed to ASCs, and that's because it's cheaper to do cases in ASCs. But that means there are spaces that we have been doing endoscopy in hospitals that are maybe not being maximized. And I would say complex EMR, ESD, for all the reasons we just talked about with anticoagulation, perforation, it's really important to do these where you have backup and somebody who can take care of your complication if they need it. And hopefully they won't, but there will be those times that they do. And I think the big argument is it's both what referring providers are asking for, and I think we were talking about social media, patients are asking for it. So patients Google what to do with a complex polyp, and they want ESD. And whether or not they want ESD, whether or not they need ESD, if your group is not providing that practice or that opportunity, they're going to feel like they're not getting the care that they perceive that they need. And in some places, it's a competitive market. So while I was saying earlier, look around and see, is there three different people doing ESD? You know, at least where I practice in Seattle, it's really driven by insurance. And it's not so much the gastroenterology groups competing with each other, it's these insurers who are competing with each other. And so making sure that your hospital catchment area has that ESD resource, I think, is important. This is where the talk is going to get really boring. So I apologize ahead of time. We're just going to briefly go through CPT codes, APC groups, DRGs, and ambulatory surgical center billing and payment. And let me know if there's any questions, because this is kind of the worst. So physician billing and payment. So this is published by the AMA. It's a code to report medical services and procedures performed by or under the direction of physicians. It's used by Medicare and most other insurers for physician reimbursement. So this is the CPT code. So when you do a colonoscopy with polypectomy, that gets labeled as a CPT 45385. And that code description is colonoscopy with removal of tumor, polyp, or other lesion with snare technique. And in general, you're going to get a provider RVU of 4.57. So keep CPTs in mind, because it kind of spills into all this other stuff. So this is ambulatory payment classification groups, or APCs. This refers to hospital outpatient billing and payment. So Medicare assigns a procedure to an APC based on CPT codes. And hospitals can receive a separate APC payment for each procedure done during the same outpatient visit. Many APCs are subject to reduced payments if you do multiple procedures performed on the same day. And in general, the highest value procedure is 100%. And all other procedures are subject to a 50% reduction. And so the example here would be colonoscopy with polypectomy. The APC is 5312. And the average facility payment, so this isn't going to the physician. The physician gets a separate payment. But the facility gets $1,060 for that. The DRG is different. So when patients get admitted, and you'll see at the bottom a two-midnight stay is the rough outline. So patients spend overnight more than two nights. So we admit patients after, say, a PEG placement, or say you put somebody on obs after a POM. They don't fall under this diagnosis-related group. They get just covered under the procedure. And then there's some ancillary costs that are billed for. But this is a system of classifying patients based on a diagnosis and procedures performed during their hospital stay. It's supposed to calibrate to the severity of patient illness. And it's intended to cover all hospital costs associated with treating an individual during that hospital stay. So it doesn't include physician charges associated with performing medical procedures. And so this example would be, say, you have a terrible bleed that happens. Patient has some issue, and they get hospitalized after that procedure. The medical national average payment for that DRG, or 377, is $6,551. It doesn't matter if they spend two days or if they spend six days. This is what the hospital will recoup. So the hospital's invested in getting the patient out earlier and doing less procedures during that hospitalization. This is ambulatory surgical centers. So there is a separate facility fee that's different than what you would get in a hospital facility. These must be licensed as an ASC. And clinics establish and set rates with payers. So it may be that the clinic has one rate with one insurance group and another rate with another insurance group, which is different from their rate that they've established with Medicare or Medicaid patients. Medicare somewhat sets the prices because they have so many patients under that. And they have approved procedures for which they pay the ASC a facility fee. And then a lot of times, the private payers negotiate off of that. Here's two examples, at least, with colonoscopy with removal of polyp by snare. And so you can see this is polyp by snare and then colonoscopy with EMR. And so one of the things that your billers will probably work with you on is if you're actually doing an EMR, which is marking the outside of the lesion, submucosal injection with lift, and snare polypectomy, that's considered an EMR. If you don't do all those three things, then it's considered a removal of polyp by snare. You get different amounts of work RVUs, so 6 versus 4.5, which adds up if you're doing a lot of colonoscopies through the day. This is how it reimburses. So for a facility, it's very different, too. So the hospital will get $1,000 if it's just removal of polyp by snare, and they get $2,500. If these procedures are performed in an ASC, it's half that rate. So this is one of the reasons insurers are pushing everybody to do their procedures in an ASC. This is why hospitals, if they don't have to, will try and keep everything in a hospital. Here's just a slew, and again, you can go to, I pulled this from Boston Scientific. All the societies have different way of putting this Excel up. But EGD with biopsy, ERCP with biopsy, so you can see a standard ERCP with biopsy is 6. These are the different breakdowns for colonoscopy with biopsy, control of bleeding, removal of polyp by hot biopsy. You can see, roughly, the hospital doesn't really care about the difference between these, but they do care a little bit about this, and then the ASC is a lower reimbursement for all these procedures. Some of the things to take into account, you only get credit for one EMR per procedure. So if you see six polyps, and you take out six polyps, you will get paid for taking out one polyp, even if you take out six. We actually had a case the other day where we ended up taking out six, and I think we spent like three hours doing it. And probably in that time, you could have had a total colectomy done much faster. But for a variety of reasons, that was the right thing to do for that patient. But there are practices that will take out one polyp, and then send them on, and then have another polyp take that out. So there are some financial considerations. And I think a lot of times, for us, the hard decision is what's best for the patient. And I think that's the question you have to ask yourself when you're in the midst of the case. So try not to think about financial considerations. There is a 22 modifier. And I think you probably heard about it, but this does need appropriate documentation. So you can't just throw on a 22 modifier at the end of all your cases, because it felt really hard. You have to document that you've done substantial additional work, and the reason for that additional work. So an example would be, we're requesting a 22 modifier due to marked fibrosis, precluding the standard resection, and requiring 90 minutes to remove the polyp. This is at least four times greater than the standard mucosal resection, and required the use of extra equipment to mitigate risk of perforation. So that would then get submitted, and then that would have to be approved. And a statement like that won't necessarily guarantee reimbursement for a 22 modifier, but it will increase your chances of getting that extra compensation. And like I said, the location where you're doing your procedures matters. So are you doing these cases in an ASC, which is going to reimburse less well? And you actually need to be a little more careful about what equipment you're using in an ASC versus in a hospital. What is your payer mix? And then what are the local payment agreements? And so that's where it's important to talk with your billing group. Yeah? So is it one polyp and one EMR, or like it's all one, like you take one EMR, but then there are other polyps, smaller polyps? So you may take out all those polyps, but your billing code is just going to be one billing code. So it doesn't matter if you take out 10 or 20. And then there's always a debate, like at what point do you get to say eight polyps merits a 22 modifier? And I don't think there is a good, there's not a standard statement across all insurers what would validate a 22 modifier. But yes, when you take out three polyps with EMR, even if you take all three out with that same thing, you're only going to get credit for taking out that one polyp. And the modifiers do not include like top colonoscopies, colonoscopies, or? You can, you just have to document it. But you know, the counterpoint would be, well, you know, is it truly that much harder than a standard colonoscopy? And you know, there is some concern that if you're continually putting 22 modifiers on, you know, they're going to look at why you're continually doing that. There's another question in the back? Shifa? Yeah. So when can you say it's an EMR? It's just like if you've injected and lift, like is there a size cutoff or is like a referral for EMR, like especially when you're putting it through probation, you know, anything that you lift and cut, like even if it's like a, I don't know, 15 millimeter polyp, does that qualify as EMR? So EMR by definition is going to be marked the outside of the lesion. So do some form of marking, submucosal injection, and a snare polypectomy, hot snare polypectomy. So anything short of that may not be considered, I mean, you can bill for it, but then you have to justify why you would not be using. So say you do underwater polypectomy, you may need to say we injected, you know, fluid around the polyp, but you may not get credit for a full EMR if you're not doing all those steps required for EMR, if that makes sense. And just to clarify, you said hot snare specifically? You know, I don't know the answer to that. Snare polypectomy. Talk to your local billing experts, but yes. So you know, again, when you're thinking about bringing on new technology, think about where you're bringing it on. It may not make sense to bring an FTRD to an ASC because you're not going to get as much reimbursement and you may not get reimbursed for the equipment you use during that procedure. Think about what it's going to cost to train staff and to get staff good at what they're doing. And sometimes, you know, even though we have all these exciting things, it's best to just go back to what is the quickest and most efficient way to get what you need done. Just a brief statement on billing for endoscopic semicolstal dissection. So there is no current CPT code for ESD. Most people are using an unlisted procedure colon or rectum. There is a CMS code for hospitals to report ESD procedures in the outpatient setting. And the average reimbursement was essentially the same as EMR. So hospitals don't see much of a difference between ESD and EMR from their standpoint. To recoup it, so because ESD is not necessarily standard across the U.S., reimbursement rates are super variable. And so people do a variety of different things. Some people will submit a cover letter with a claim explaining why you're doing the procedure. So what is ESD? What's the equipment required? What's the estimated practice cost in comparison of physician work time with other comparable services? And then often, it's helpful to provide some data why you're doing ESD. And kind of the main statement that we currently have is from the AGA clinical practice updates. A lot of times, what happens is your patient will be pre-authorized for the procedure. So you may see that, gosh, they've been pre-authorized, but that doesn't guarantee that you will get reimbursement for the procedure. So you can ask for a separate predetermination, but that could be rejected, and you have to prepare patients that that may take two to four weeks. So a lot of folks, when they're doing ESD, and again, it may be better to talk with the ESD folks, because I do not do that part of things, is how much time are they spending on this pre-authorization versus predetermination request? And a lot of times, it may result in a peer-to-peer discussion, so you have to have a discussion with another physician. So there is a lot of time on the front end to just try and get guaranteed reimbursement. Dr. Offman published his single-center analysis, so they looked at ESD between 2017 and 2019. And this was looking at both upper and lower ESD. And you can see that the government mean charge was higher than for private, and the mean payment was actually lower for government than for private. And in general, the average payment per procedure for esophageal was almost 900, gastric duodenal was a little less, and then colon and rectum was higher. And again, you can somewhat, and I think in his paper, he broke it down into an hourly rate. So this is what you're going to get. So if you're spending five hours, you're not getting a very good hourly rate for your procedure. So I think the take-home for me, at least, is right now, there's a big need for these skills. But before you embark on taking on these skills, really think about what it means to you to take on this practice, why it's important to you, does your community need it, and then how do you use what you have available to you? So there is a reason for a hospital to bring on ESD. But to make that argument is going to be a little bit of an uphill battle, particularly initially when you're spending a lot more time on it. And make sure that your nursing and tech team are supported in investment, so when those cases get long, they're not pushing you out of the room. And then work within your referral base to make sure that you're going to have some continuity of patient care and success long-term. And then work with your team to support innovation and practice improvement, and the administration to support billing. Questions folks have? All right, well let's get off to lunch.

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