usually the point where the speakers thank you, the organizers for inviting them, and I cannot be more grateful to be part of this as distinguished as it gets of a group of faculty. I mean, this is who is who in ESD in the world, forget about the United States. So it is a true honor. At the same time when Nouriel gave me this topic, I said, oh my gosh, people show exciting videos of ESD and I'm going to talk about reimbursement. How boring can it get? But here it is. So I'm going to talk about reimbursement for physicians and then reimbursement for facilities because those are two different things. As you're probably painfully aware, there is no dedicated CPT code for ESD, and the recommendation is to use unlisted code for the physician reimbursement. Here I have listed for you the corresponding CPT codes for various locations throughout the GI tract. Keep in mind that rectum is different than colon, and small intestine also has its own separate location. Because there is no dedicated CPT code, the beauty of it is that you can charge whatever you want. Your institution sets your price. The bad thing is that in most cases it will be rejected, and it will be denied, and you have to submit an appeal. So be prepared, basically every case that you do to submit an appeal, and you should prepare a letter with that appeal, listing the things that I have listed here. What is the nature of the procedure? The equipment required, estimated practice cost, and comparison of the physician works with other procedures for which we have reimbursement code. For example, you can use a complex ERCP. Cannulate, do sphincterotomy, extract stones, do a cholangioscopy as a reference point, because ESD is at least as complex as that. You can provide the billing companies some reference of the amount of time and effort that you spend on ESD. You should provide some literature support. I think this expert review that Nouriel was kind enough to get me involved, it's a good paper to attach with your cover letter describing the procedure. Certainly, you can use any US-based type of study, but it has to be US-based. You cannot use a Japanese study to support your claim. The reason I'm singling out this paper is because it talks about indication, because the most common rejection will be that this could be handled by EMR rather than ESD. Here in this document, we outline the indication for ESD. I'll give you a heads up. Currently, we're working on the ASGE guidelines for ESD that will be US-based, but it will be probably about a year before those get published. Now, on the facility side, the situation is different. For now, about a year, we have a newly created code, and this is the code C9779, that may be used for hospitals to report ESD procedure performed in outpatient setting. The key is that the patient has to come to you as an outpatient. You can admit them afterwards, but they have to come to you as an outpatient. Of course, the problem is that the reimbursement is basically roughly $2,500, which is not that much considering the price of the devices that we use, because a very straightforward ESD where you use a distal attachment or cap, a single knife, and a quack grasper will already get you over that amount. If you start using various retraction methods and so forth and so on, then you will be clearly deep into the red. But this is the CPT code for reimbursement. This is, in most cases, not your concern. This is the hospital concern because I doubt anybody does ESD in their own ambulatory surgical centers, right? I mean, everybody does them in the hospital. But you may relate this to your administration if they are not aware of it. So I want to pause here to see whether there is any questions related to this. I mean, it is very straightforward for me to outline it, but in practice, obviously, you get multiple rejections, and you have to be well-prepared to deal with those. Okay. Peter. Yes. You know, with this discussion, many times we're advised to submit unlisted code as many as possible so that Medicare can be aware that this procedure is getting more popular. Could you comment on that? I completely agree with that. So, guys, the way this works is in order for us to go to CMS and request a dedicated CPT code, one of the requirements is enough of the procedures being done in this country. If, let's say, in the United States, we do 10 procedures per year in the whole country, and you go to ask for a code, they say, why the hell do you need a dedicated code? I mean, that's what the unlisted code is about. For rare procedures, hardly ever done. So the more we do and we submit this under the unlisted code, eventually you can justify the need for dedicated ESD code. And I was part of the panel trying to work on the submission, which had to be withdrawn about a year ago for various political reasons that I don't want to get into. But one of the biggest challenges we had is to determine how many ESDs are done in this country. And there is no good way to track it because we don't have a dedicated CPT code. So then another kind of fairly obvious answer is, well, let's go to the companies and see how many knives are sold, and that will be a rough estimate of ESDs. Well, good luck. Companies keep that information very close to their chest, and they're not easily willing to share how much knives they sell per year because of trade secrets and so forth. So that turned to be a major obstacle, but I will totally reinforce what Nouriel said. The unlisted code submission is the way to go, as opposed to because some people submit injection code, hemostasis code, you can kind of piecemeal your own submission based on existing procedure codes. But actually I find not only to be better from being able to track procedures, but also actually it reimburses better because, again, you can charge whatever you want. Yes. Would hybrid ESD qualify for ESD code? Everything qualifies because there is no CPT code. I mean, you can make it whatever you want. It's unlisted code. Yes, Sergey. Peter, I think that this is the wrong way to trying to get the number of ESD by number of the knives sold because frequently for one ESD you use more than one knife, plus several companies are manufacturing knives. That's multiply the problem. The easiest way probably to calculate the number of ESD in this country to ask Olympus and Fuji how many distal attachment and ST hood sold because they use only one for one procedure. So this is easy information to get and there's only two companies which are making it and you don't do ESD without ST hood or distal attachment. That's a great point, Sergey. I think that's the way to go. And plus some knives are used for POEM. Yes, yes, but some ST hood and distal attachment used for POEM too, but nevertheless there is no SPT code for POEM either. There is now from the last year or so. The challenge with that is we also use distal attachments for EMR. EMR, yes. Yes, but still. I mean it's a very thorny problem. The attempt for the CPT code was to be its own procedure rather than being a family of procedures. For example, if you do EMR, the CPT code for EMR is EGD with EMR or colonoscopy with EMR. So you have a family of EGD codes and a family of colonoscopy codes. And EMR is part one of the other family. What we were aiming for is to have ESD as its own procedure rather than EGD with ESD or colonoscopy with ESD. And that met significant political resistance for various reasons. So the application was withdrawn and then the hope is that it will be resubmitted this year once we gather enough political momentum. I wanted to point out that hybrid ESD, you have to really define what you're doing. We're kind of mixing up hybrid EMR, hybrid ESD. If you don't do dissection part and describe, you're almost charging a fraud. You're doing EMR, just adding incision doesn't qualify for ESD. So be careful what you're doing. If you're doing dissection to some extent, then add the snare. I think that's acceptable. So that's one thing. The second is if you're doing probation, you can add at the end, there's a billing code that comes up. You type in the number. I know it says 43499 is unlisted for esophagus. 43999 is stomach. And 45399, I don't use that often, but I should. Yeah, you're correct. No, no. Actually, I don't remember. I just type in unlisted and then look for the rectum or colon. There's a rectum, right? There is a rectum, yeah. So you can choose that. Make sure that you choose them so that your billing person is aware that you're claiming unlisted code. And you have to eliminate some other charges as well. So please do that. One of the virtual attendees was asking, how about asking pathologists what kind of number of specimens? That can be really challenging as well. The main thing is that there is adequate claim, the really legitimate claims requested so that they can think about reimbursing us. And we have to really be honest and put our effort in there. Otherwise, they will come back with very minimum payment. Well, I'll defer. Actually, I think we had that discussion not too long ago with industry about how many people actually are doing ESD. And it's not that easy to figure out because guess what? I have monitored our own University of Florida course. Our batting average is around 40%, meaning of the people that come to us to train, only 40% end up actually doing ESD in a meaningful way. Because people have the good intention, but there is so many obstacles, credentialing and you name it. Absolutely. And the quality of the faculty as well. But anyway, let me quickly go over this because we are running low on time. And I realize that I am the only barrier in between you and the lunch over there. Peter, one question from audience, virtual audience. Should ESD code based on time? Well, that was the discussion. Should it be based on time or shouldn't be? And basically, if you look at any other procedure, basically none of them is based on time. Laparoscopic cholecystectomy is not based on time. It's just laparoscopic cholecystectomy. And then the other option is should it be based on size? That's another potential option. But that's again, when do you measure the size? Based on endoscopy or after you pin it and stretch it as much as you can? I think that it should not be based on time because then you penalize people who perform it faster. Then it is the wrong thing to do. No intention to master your skills. So it should not be based on time. Quality metrics in ESD. So we don't have a commonly accepted quality metrics. But the Europeans came with 10 metrics. Indication. Use of morphologic criteria for the evaluation of the lesion, such as in your report describing Paris classification. JNET or NICE, whichever one you're using. The supposed diagnosis. Unblock R0 oncologically curative resection rate. Histology, technique use, standard versus hybrid. So those are five and those are the other five complications, of course. Volume of ESDs performed per year. Lesion location. Need for surgery after technically successful ESD. And time taken to perform the procedure. So those are the 10 parameters proposed. There is no consensus what you should be looking for. And we've been discussing on the AGA side. Let's say the commonly accepted quality parameters are unblock, R0 and curative, right? Well, nowadays unblock has become almost irrelevant because everybody is 95 and above that routinely does ESD. And the other parameter that you should consider in unblock, obviously one is the skill of the physician. But the other one is the lesion. And what I wanted to point out to you is that the ESD outcome depends on multiple factors. Technique, devices. I mean, if you have the right traction method, you may do much better if you don't have a traction method. Lesion selection is the key. And, of course, prior endoscopic intervention. It is unfortunate that Dr. Nishimura could not join us. He should have been here. But he moved from Japan to the United States. And in Japan his unblock resection rate was 96.5%. He moves to New York and his colonic unblock resection rate goes down to 73.5%. What the hell happened? I mean, he lost his skill? Of course not. It is the type of lesions that we have to deal with in the United States. They're frequently biopsied. They're frequently partially resected with a snare and then sent to us. Or they're tattooed underneath the lesion and there is severe fibrosis. So how do you factor that into the quality metrics? Obviously the U.S. metrics may be different than Japanese metrics. I forgot to mention the example that Dr. Aihara gave us, the 300-pound patient. It obviously is more difficult to do ESD, colonic ESD in particular, in a big patient. So just food for thought. But for now probably I would say that unblock R0 and oncologically curative resection rate are the main quality parameters that you should be keeping up when you're doing ESD alongside with complications. Those will be the two main ones. And this is a brief summary of the coding discussion that we discussed extensively. Thank you.

reimbursement

endoscopic submucosal dissection

CPT code

unlisted code

quality metrics