Welcome. The American Society for Gastrointestinal Endoscopy appreciates your participation in our newly branded Thursday Night Lights webinar series. Tonight's event is entitled Reimbursement for Complex Endoscopic Resection, Navigating the Torturous Road. The discussion of this webinar will focus on how to establish a sustainable complex endoscopic resection program and the current reimbursement of the physician component of ESD and suggestions on how to fit ESD practice in an RVU-based system. My name is Reddy Akova, and I will be the moderator for this presentation. Tonight's session is brought to you by the support of Lumendi, a global medical technology company that is committed to creating technologies that enable endoscopists to perform at a higher level and minimize risk and recovery time for patients. ASGE greatly appreciates Lumendi's support tonight. Before we get started, just a few housekeeping items. A quick disclaimer that the views and opinions expressed during tonight's webinar are those of the presenter and do not necessarily reflect the official policy or position of ASGE. There also will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question box in the GoToWebinar panel on the right-hand side of your screen. If you do not see the GoToWebinar panel, please click on the white arrow on the orange box located on the right-hand side of your screen. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASGE's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now, it is my pleasure to introduce our presenter for tonight, Dr. Mohamed Othman. Dr. Othman is a board-certified and fellowship-trained advanced endoscopist. He's an associate professor of medicine, gastroenterology and hepatology section at Baylor College of Medicine and is chief of gastroenterology section at Baylor-St. Luke's Medical Center. Dr. Othman graduated from University of Mansoura School of Medicine in Egypt and shortly after began his residency in internal medicine at University of New Mexico School of Medicine, which was followed by a fellowship in gastroenterology and hepatology. Dr. Othman his advanced GI fellowship at Mayo Clinic Jacksonville in Jacksonville, Florida. Following his fellowship at Mayo, Dr. Othman accepted a position as an assistant professor, division of gastroenterology department of internal medicine at Paul L. Foster School of Medicine, Texas Tech in El Paso, Texas, until 2014 when he joined Baylor College of Medicine in Houston. Over the last 20 years, Dr. Othman has been the recipient of various research grants and has been widely published in many peer-reviewed scientific publications and book chapters and is a regular speaker on the academic circuit both nationally and internationally. With so much experience, we are very fortunate to have Dr. Othman present tonight's webinar and I will now hand the presentation over to Dr. Othman. Well, thank you so much for this nice introduction, really, and I'm very excited to talk about a new topic that we usually talk about the technicality of the procedure, but today you are going to talk about actual building a program and establishing an EST program in the United States. And part of establishing a program is to figure out how to have reimbursement. It is different when you do one procedure every three months, one complex polypectomy every three months, versus when you do that in a daily basis or that's like maybe 40 or 50 percent of your practice. And I'm going to go through my experience, and it's my personal experience, and how to build an ESD program in the United States, including the building part. So before we talk about the ESD, we want to talk about the EMR in the United States. And EMR is well-established procedure. It was started to be used in the United States before ESD, and for that reason we have a dedicated CPT code for billing for EMR, although that code did not come until maybe 2013 or 2014. So even the EMR code in the United States is a new code. However, the different techniques of EMR, either with CAB, without CAB, and with underwater or without water, all of these are acceptable and published, and in a way become a mainstream in the United States. In fact, we have ASGE courses dedicated for EMR. It's called semester classes for EMR that ASGE has been doing them for years now, was focused on improving the technique in the United States of doing EMR. So in comparison, if we look at the ESD, that was my first publication, ESD in 2011, was my mentor, Mike Wallace, and at that time, ESD in the United States was not that common. At that time, there was very few centers doing it. A few lesions starting only with gastric lesion, we're talking about hybrid techniques mainly, which is EMR and part of it ESD. And even for colonic lesion, we're thinking it is a little bit too much to do ESD for colonic lesion at that time. This was our thinking. And jumping now 10 years later, in 2021, ESD is gaining popularity in the United States. I would say we have more than 15 ESD referral center in the United States. And when I say referral center, I mean center who are doing at least 50 procedures or more annually. And that number is increasing. This is the one I know of, and I know people who are doing these numbers. I would tell you three, four years ago, there were maybe four or five centers only. The ASGE now have a sponsored training for ESD called the Asian Master Course. And it is a great course. I took it personally in 2013, which was the first class in 2014. And I would say that course is how I built my connection with the Asian Masters, how I end up going after that to Japan and China was through that course and through meeting people in that course and building this relationship. ASGE continued to do this course, and it is one of the most successful courses for teaching ESD in the United States. Also, ESD is an area of planned expansion for every major academic center. So in every place, there is a need for somebody who can do complex polypectomies and removing large lesions and also dealing with submucosal lesions. Although we don't have somebody dedicated for that in each center, I would envision the same like what happened with endoscopic ultrasound. It will happen with ESD, and very soon we'll find dedicated personnel for ESD in each academic center. So what's the downside? What's holding ESD back in the United States? Number one is that we always have this debate between EMR and ESD. Why I will do ESD if I can do EMR? And the results sometimes are comparable, but definitely there are certain lesions that you need to do ESD for. But rather we're doing EMR or ESD at the end of the day, endoscopic techniques are also competing with surgery. And that's one of the major thing we're seeing or trend is that labroscopic surgeries for colon cases or colon lesions are increasing. And we're going to show slides about that. So there's always this debate why you do all of this. You can send the patient for surgery and get it done well. Why you remove a gist by endoscopy? We can do wedge resection and take care of it. And also we do not have enough data from the Western endoscopists showing the superiority of ESD. So we have a lot of publication about EMR, but most of the ESD data is coming from Asia, particularly Japan and China. And when you try to present this data in the United States, they will say, well, they have a different patient population, they have a different disease, and maybe whatever applied to them or whatever successful there is not successful here. Reality is, I would say it is the same. However, we have to prove it. We have to have our own data showing the superiority of ESD, which we are in the process of doing now. So I want to show this slide here, which shows the annual incidence rates for the non-malignant colorectal polyps and colorectal cancer surgeries in the United States. What we're seeing here in the dotted line, that's a colorectal cancer. You can see the rates of surgery are decreasing over the years. So what about the non-malignant colorectal polyps? Actually, they are increasing. Part of understanding reimbursement for ESD is to understand this slide. In the United States, we have an obesity epidemic. That obesity epidemic has many drawbacks. One of them is that many patients will develop colorectal polyps that will be larger and also at an earlier age. So we heard about right now that the US Task Force would like to start screening colonoscopy at the age of 40, because we have enough evidence that the rate of colon cancer are increasing in patients who are 40 years old, between 40 to 50. And then, on the other hand, because of obesity too, when you try to do procedures for this patient, it is very hard to do the colonoscopy, let alone removing complex polyps. So gastroenterologists will just send this patient for surgery. They say, you know what, it took me half an hour to reach the colon. This patient is 350 pounds, and this polyp is in a tough location behind the fold. It's better to send the patient for surgery. So now we are getting this trend that we have a sicker patient with larger polyps, and instead of investing in endoscopic techniques to help them, most of this patient is going for laparoscopic surgery. And what is the surgery? It is either right hemocollectomy or left hemocollectomy, which is a major surgery. You're almost removing half of the entire colon for a benign polyp. And although maybe some of you practicing in academic centers, once you go to private practice, once you go to a smaller center, you'll find that it's totally acceptable that 5 centimeter or 4 centimeter polyp in the right side of the colon that's totally benign and tubular adenoma will be treated with right hemocollectomy. So in a way, if you think about why endoscopy is better for this lesion, if you look here from the healthcare system perspective, a surgery will cost at least $15,000 versus endoscopy $6,000. And that's in Australia. United States, it could be even more expensive, but that's an Australian study showing the cost of endoscopy. And the one in green here is the cost of endoscopy, including anesthesia, and including that the patient will have another follow-up endoscopy. And that's your cost of surgery. And of course, that's a huge difference. If we look at the actual endoscopic mortality based on physiological score, and physiological score, the higher it is, the sicker the patient. And we compare the actual endoscopic mortality with published data about protected surgical mortality, you'll find in very sick patients, the one with liver disease, the one with chronic kidney disease, who have physiological score above 15, you can see here the surgical mortality is increasing from 12% to 28%, but the actual endoscopic mortality is 0%. And I want to stop here for a second and talk about why this happened. There is something about opening the peritoneum that stimulates a cascade of inflammatory reaction. So going to the peritoneum from the skin, in a way, is more traumatizing than dissecting the polyp endoscopically without causing perforation. And also, even if microperforation happened during the procedure, they are easily manageable, and you are not exposing the patient to this intense inflammatory reaction. So basically, it makes sense. Endoscopy is cheaper, and endoscopy is actually safer. And in spite of that, the argument is hard, because we're not able to make successful polypectomies program, which in this situation will be based around ESD. So how can you have a successful ESD program? You want to address the need of the population of interest. So you cannot have an ESD program for gastric cancer in a population that doesn't have gastric cancer. You're not addressing the need of your population. So unless you are in a city that has a large number of patients who are from Asian descent or Hispanic, and you can discover gastric cancer early in the United States, doing ESD for gastric cancer is very rare. Also, you need to provide values that are superior to other modality. So you want to prove that the ESD is much better than surgery, which we just talked about right now. And also, you want it to complement already existing programs you have. So if you have a successful endoscopic program for doing colon resection, that would be something to implement. If you have a large practice of EMR in the United States, you can convert your EMR practice into ESD. So we'll talk a little bit about the colonic ESD in the United States. And we can see here, when we talk about ESD, we're talking about the submucosal layer. And we're basically focusing in removing the entire lesion in one piece. That's an example here of lesions that are removed by ESD. In the first slide, and I chose this picture just to show the complexity of this procedure. So in the first slide, we can see here, we're using an assistive device for stabilization. We're using another device for grasping. And we're using a specialized knife to dissect the lesion. And you can see here the muscle layer under it. And you're working in a space like two to three millimeters to remove that lesion. Picture on the right side here, you can see a very flat polyp removed by EMR before. And you have this fibrosis in the middle. And it's really hard. You can imagine if you're doing EMR, it's really hard to do EMR for a lesion like that. Down here, that's the appendix. And that's another tubular adenoma in the appendix. And you can see here that the lesion is taking the appendiceal orifice. And it's actually closing the appendix. And there's pus coming out. It's a complex lesion in the past. Something like that would be sent for surgery. And here is an example of the end result of removing this lesion with ESD. You will have the polyp completely removed in one piece. And you are going to have all the margin around it very clear and very nice. So, these are examples of lesions, lateral spreading tumor, granular, non-granular, specifically non-granular. We want to remove them with ESD. Flat lesion, by product lesion like this one here, or appendiceal orifice lesions. So, there is a need for this in the United States. We see a lot of these lesions, and we'll continue to see more of it. And as we saw from this picture, to have to do an ESD process, you need a lot of devices. You need an electrosurgical unit, injection devices, resection devices such as snares and knives, ablation devices, hemostasis devices. And you also sometimes need stabilizing devices and tissue opposition devices like clips and other. So, if you think about this, it is really costly. But if you also think about the cost of surgery and the cost of going to the OR room to do right or left hemocolectomy, and you see the amount of devices you are using, you will discover that although we are using all these devices, it's still cheaper than going for surgery. So, how do you go about that? How can you build a program with all of this? And particularly for ESD, as we see here, you will need a lot of clips. Clips are not that cheap, and that's why we need to develop more and more of these cheaper options. And I know some of the companies now are coming with cheaper clips. Clips were very expensive in the past, and now we can find them at cheaper prices. Stabilizing devices are also important for chronic ESD. So, decreasing the cost is important, but also convincing our administrators and the healthcare system by the utility of ESD is important. That's here comparing EMR versus ESD, and we show here that procedure time for ESD is longer. This is another thing. So, it's not only that I'm using too many devices. You are spending longer time in your room. So, as we can see here, it's 100 minutes for ESD versus 29 minutes for EMR. But if you look at the recurrence rate for ESD, it is 0.9% versus 12% for EMR. That's a huge difference in terms of the recurrence, and if one of these recurrences leads to cancer, then ESD is really saving the healthcare system and the patient in this situation. So, it's longer time. It requires more procedure, and also does not have a CBT code. So, establish this program with reimbursement is even harder. Add to that, that yourself, you have to invest in yourself to learn ESD. So, I'm going to tell you that my experience is that I started my interest in ESD in 2011. I started doing animal labs between 2011 to 2014, and I did basic labs and advanced animal labs, like life animals and courses, and later on, I started doing ESD in 2014. My practice is that I picked up to become a real ESD practice in 2017. Now, by 2021, like last year, 2020, I did more than 300 ESD a year, but to reach that number, it took me around nine years of starting interest, which was in 2011. So, you have to have a basic precondition. You have to be in a referral center, have experience in EMR. You don't have to be a senior endoscopist, but you cannot start out of fellowship interested in learning EOS and learning ERCP, but also, in the meantime, learning ESD. ESD requires focus, and if you are not feeling comfortable with ERCP and you are chasing each and every ERCP you are seeing, then you will not have time to learn that. So, it's not about being a senior endoscopist, but I would say two or three years out of fellowship when you're not that worried about your ERCP skill, or from the beginning, you're just focused on complex polypectomies, as they do in Japan. They just either go for ERCP routes or for polypectomies route, and they even divide the ESD routes into upper and lower. Then, after that, you have to make a structural decision, and what I mean by that, you're going to spend two hours, three hours in the room. The worst thing you can ever do is to plan your first ESD case, and you do it in assuming it will be finished in one hour, and you spend three hours and everybody knocking on your door because they have another patient after that. So, you have to plan it very well. You have to have at least half an hour, at least two, three hours for the first case, and you have to communicate that with your system that you are still in the planning stage. Otherwise, somebody may write a complaint about you to the hospital, and that's happened to me at the beginning, and they sent to the CEO saying, Dr. Othman, he spent at least three hours doing an EGD. So, basically, you have to explain to them that this is not an EGD, and that is an ESD, and once you reach to 40 or 50 case, that would be very comfortable. Now, we start to look for your outcomes, and what are your outcomes? You want to look at your R0 resection rate. You want to look at your curative resection rate, and you want to achieve a R0 resection rate of at least 90%. Curative resection rate depends on the lesion, but between 70 to 80% is important. So, these are the steps of learning. So, it's a complex procedure, takes a long time, and you have to invest in yourself for a long time, and after that, you have to build all the surrounding in order to ensure good reimbursement, and the first thing is excellent endoscopy team. Then you have to have supporting hospital administration, and you have to educate the physicians in the community. So, remember, these gastroenterologists who are sending the patient for surgeon, they will be the one who are sending you the cases, and in order for them to be convinced, you have to talk to them, send them brochures, send them pictures, make updates in your website, or even just show them pictures of the lesion. Tell them, you see, that's one lesion removed. If you have a patient like that who you think can go for surgery, I can save your patient's surgery. Also, you have to have a good relationship with the surgical team. Explain to them that you may have lesion that people refer to you, that they could not be removed by endoscopy, and we'll send it to them. Also, we need them for backup if complications happen. So, endoscopy team is extremely important. That's a picture of my endoscopy team at Baylor St. Luke's, and I owe them a lot of my success, but there is something important about technician and nurses. You have to limit your ESD to at least three teams. I would say maximum three to four teams, and I will tell you and save you time. They're going to come and tell you, we have to train everyone because everybody has to be cross-training, and cross-training is something big in the United States. Everybody has to be cross-trained. People like to say this word. It doesn't work for ESD. So, your answer would be the following. Cross-training is great, but ESD is an outpatient procedure. I will only do this procedure when I'm planning it. I understand that some of the staff may be off. Training two to three techs are all what we need. You don't need to train all the techs in the unit, and tell them not every physician are doing this procedure, too. So, as long as gastroenterologists are subspecializing, our technician and nurses will be subspecializing, too. Kind of start training two or three. After that, if you want to expand, that's fine, but do not do each procedure with a different person who they do not understand the electrosurgical unit and don't know how to deal with the devices because they will stress you out in your beginning of your experience. And knowing this energy setting is important, and when you are so busy and you're asking for the coagulation grasper, you may forget to tell your assistant, please switch to soft coagulation. So, because you are in a hurry, you want to control that bleeding. So, him knowing that and him knowing how to switch the setting for you is very important for her, and to train him or her, it doesn't require only one case. It requires that they share you and be part of that journey. And the same will happen for your anesthesia team. You have to encourage them to help you and encourage them to do general anesthesia, especially for right-sided chronic lesion. And also, you teach them to follow the peak inspiratory pressure and see what's the peak inspiratory pressure at the beginning, what will happen at the end, and tell them, tell me what's going on. If the peak inspiratory pressure increase, that's important for me, because that's when you have tension in your abdomen, and knowing all this stuff is important, and teaching your staff will be helping to have the successful team. Then, supporting hospital administration is a tough part, and it depends on where you work, because the argument for ESD and how the hospital can make a good reimbursement for ESD depends on how you will spend it. At the end of the day, they make money from surgery, too. So, if you go to your private practice hospital and tell them, I have these awesome techniques that will help my patient, and I'm going to introduce all the colorectal surgery in the hospital, and I'm going to do half of their practice, they don't like a discussion like that. It's better not to talk this way. It is better to focus on the referral pattern, better to tell them that this patient will never come to our system, but because we're offering something unique and something noninvasive, they are coming to our system. It's better to tell them that maybe the other hospital next to us is offering that technique, and if we don't offer it, our patient will go for this noninvasive route. It is always nice to tell them, and some of these patients who are referred to us, they actually may need surgery, and we'll send them for surgery. I remember when I started, and I came to Baylor, and I was doing ESD, and I started doing ESD for high-grade dysplasia and early esophageal cancer. The chief of cardiothoracic surgery at the time met me, and he was very upset, and he was one of the old-school surgeons, and he told me high-grade dysplasia should be treated by surgery, an esophagectomy, and you better make sure that these patients are not getting recurrence. Actually, that was good because it made me very careful. It made me have a good database and follow up on this patient, but guess what? Our number of esophagectomy doubled after I started doing ESD because we will get some referrals that we think are suitable for ESD, but actually, they end up going for surgery. They end up staying in the system later on for other things and for CT scan, so there is always downstream revenue from that. If you are working in another system, something like Kaiser, something like closed network system, when the insurance owned by the system, then the cost saving is very important. Then when you tell them, I'm going to save the system by doing ESD, they will be excited about doing it, but also be careful because in this network, large network system, they will also have to assign certain people to do it, and it will be hard to prove why you are the one who will do it and not other one. If you are in a smaller hospital, it may be harder to convince them because you will say, refer it to the major hospital, but focusing and cost saving in a system that's large network system, that's very good. Focusing and referral pattern in a private hospital and small hospital will be the winning argument. Of course, if you are in a major academic center, then focusing in the U.S. news ranking and being competitive in academia and publication will be another thing. If you work with your chief, and now your chief asking you, you want to do ESD, and how can you justify doing one case in two, three hours, you have to explain to him that this is how we're going to be competitive, and it is a period of time, and I'm going to get better. In a way, you will have to convince them that by doing that, they are getting better. As you can see here, it is multiple argument for multiple people, and you have to know who you are talking to because although all of us are interested in better outcomes for our patients, when it comes to how healthcare system work in United States, there is a lot of other consideration, and as physicians, we have to be aware of it. And there is no healthcare system or no way of running the healthcare system that would be, I would say, 100% kosher. There is always consideration, either cost consideration, either new innovation and techniques and how you consider doing them versus established techniques. So, although this is annoying, as a physician, we have to deal with it. We have to be comfortable dealing with it, and we shouldn't be upset. At the end of the day, we should be proud that we're helping our patient and doing something good for them. So, the billing process, how can you get reimbursement? If you just do the cases, you will find out that you're going to have a good amount of rejection. So, I learned after a while that if you are in a system that's specifically our view-based system, and you tell them, I'm doing a procedure that's not having a CBT code, they are going to use something called, they have a reference book, and they look at the unlisted code, and they see that the unlisted code equivalent 6R view. That's how it is right now, based on university practices. If you're going to do colonic ESD or esophageal ESD for 6R view, that's very bad. That's even less than ERCP. You cannot justify that. So, in order to justify it, they may tell them you know what I am generating more money from this procedure but in order to generate more money you have to make sure that the insurance will pay for it and for insurance have to pay for it you have to go through this process that I'm going to explain to you right now number one you have to write in every patient I do I write the letter of medical necessity that letter is prepared if it is esophageal adenocarcinoma different than the letter will say the following patient blah blah blah has this condition the standard treatment by surgery is this we're doing ASD because it does this and this and that and that's cost-saving for the insurance and I write that in the letter of medical necessity and we explain everything about the ASD in the letter and then we send the documentation of the medical record with it and we also send additional data about ASD efficacy and the one that I suggest that you guys use is the AGA clinical updates it was published in 2019 and it's showing the indication of the ASD and people respect clinical practice updates it is we don't have guidelines yet for ASD in the United States but that's as close as it can get to guidelines which is the AGA clinical practice update about ASD of 2019 and I'm going to show it at the end to my discussion so I send them that and it's a very hard to argue with the clinical practice updates then what I'm saying right now is what I do in my practice and I want to stress again that that's not the opinion of the ASGE that's what I do for my practice and it's just a suggestion for you I use generic code and this unlisted code that I'm using firstly 499 for esophagus 43999 stomach and 45399 for colon and then I put the regular HDN colonoscopy code then you will have two pathway if you are going to Medicare you cannot do anything you just will send all this stuff but you cannot ask for pre-authorization predetermination you do the case and you send all this documentation to them and then but if you have private insurance then I submit for something called voluntary predetermination request so the insurance company you will tell you just do the procedure and we'll talk after and you tell them nope I don't want to go through this route I don't even get pre-authorization I want to get predetermination request so there's a voluntary predetermination request is that it mean that you are telling them I want 100% reassurance from you that once I do this procedure I'm gonna be paid for the problem was doing voluntary predetermination request that it takes at least between 15 to 30 days and if you're doing colonic polyps mostly benign this would be good if you're doing esophageal cancer you can just expedite it right away to get it in the 15 days but it's not going to be done next day it's not going to be done even within a week the minimum is two weeks so when you do this voluntary predetermination you're going to end up with two results either they accept to do the case and they tell you are approved then you schedule it or they will say we rejected and you can go for peer-to-peer and in this situation I do the peer-to-peer with a physician and I would tell you most of the time they will accept it so you will ask me why I would go through this painful route of doing all of this and and the reason is if I really just do this procedure was pre-authorization without getting predetermination I may get 50% rejection rate and there will be no evidence of how much money was in rate because I am doing the colonic ESD for 12 RVUs or 14 RVUs and that based on the how much this procedure is paying for and when we bill we bill by the hours so I will write in my note I spent 100 minute I spent anybody 80 minute doing that and we tried to bill with this unlisted code two to three times the rate of EMR so at the end of the day you're gonna be getting the equivalent money like if you look at how much you get from us and you look at how much you get from ESD procedure you will find that the equivalence around 12 to 14 RVUs and this what I get from my procedure was then my system based on my history of collection and how I built a good history of collection is by using that system that I will only do the procedure that are approved for predetermination obviously if you are still at the training stage and you're trying to find one or two lesions to do that's fine you don't have to do that but once you have 50% of your practice as this patient you cannot afford doing patient who are not approved for the procedure so what I'm showing you right now if data from 163 patient insurance claims that done at Baylor to get this data was so hard it's almost was like an act of Congress to get this data from Baylor I was able to get the physician reimbursement data on the condition is that when we talk about insurance we're gonna lump all private insurance under one name because you cannot specifically discuss the details of each contract that you have with other company so I'm not gonna use names like Blue Cross Blue Shield or United Healthcare we're gonna use the word private insurance and also we're gonna use the word government insurance to refer to Medicare and Medicaid and everything as you can see here that's for esophageal ESD we charge around two thousand eight hundred and thirty nine and it's the range is between fourteen hundred to four thousand five four thousand five hundred and that's what's my billing department based on my note asked for our mean payment rate is around eight hundred and eighty six for esophageal ESD and the range between as low as hundred and twenty one and as high as four thousand five hundred so this could happen too and if you divide that by how much you have spent time working you will find that the main payment per hour for esophageal ESD in my practice is four hundred and seventy one dollar actually it's not bad it's not great but it's not bad it will allow you to have a sustainable practice for gastric and ESD the payment is slightly higher three thousand twenty six mean payment here to ask for three thousand and mean payment is seven hundred but if you look at the colorectal ESD which a majority of my practice for ESD you will find that our reimbursement physician reimbursement component is thirteen hundred twenty five and the range the lowest is fifty five most likely you know what type of insurance will be that and the highest was three thousand five hundred and as you can see here mean payment per hour significantly higher seven hundred and fifty five in my practice I do maybe sixty to seventy percent as colorectal ESD as a result of this and if you are in a system that's very savvy and a Baylor College of Medicine are so savvy they collect all the information about how many patient you see how many patient you do how much collection you have how many are views and they came up with this formula if you're gonna do esophageal ESD we're gonna give you nine our views if you're gonna do colonic ESD it will be between it will be twelve and a half hours to or 13 our view so based on their collection they figure out that colorectal ESD is higher and the reason is the code for the colonoscopy slightly higher anyway than esophageal but that should be guide for you that if you really do predetermination and you only do approved cases this what we'll get and in spite of that we had also some cases of denial as you can see here's there's a range of denial and this the range of denial the number here is the number what we asked for you look at if you divided the insurance by government versus prices but brevity will find that for all ESD the mean payment is nine hundred oh five dollar and for private is eleven hundred but it's still even in private insurance there's huge variation and the reason is we don't have a listed code but in spite of that private insurance overall Bay better than MIDI like government insurance around two three hundred dollar and if you standardize that per hour because it's very important to know how long it take me because if you are getting paid nine hundred dollar per procedure but you're spending eight hours doing it then you are paid getting bit by our hundred dollar but if you are fast enough and your main payment per hour would be higher and we can see here the main payment per hour for my procedures around 426 or government insurance 660 for private insurance and what I'm showing you guys is this a real data and this actual practice and my practice so if we look here that's how the payment based on time and you can think in one hours if you are doing two colonoscopies probably are going to do the same if you are so fast and doing through colonoscopy you're gonna make much more money but anyways if you are in the business of doing ESD you just want to make sure you get by because ESD reimbursement is not that high yet in United States so what is the rate of denial claim denial is around 25% in spite of all what I'm doing but that was initially at the beginning after that better and there's no difference between government versus private insurance or no difference based on ESD location for what get denied it's just some reason they get denied and this very interesting and and a lot of time when patient get denied it is a process problem so we asked for predetermination we thought we had it but we did not have it and most of the cases but you have 25% denial rate and still that's in my opinion was very high so if you ask me what are you getting reimbursed for EMR and that's here the range between 106 529 was a mean of 250 or 260 dollar so still for ESD I'm getting two to three times the EMR but when I'm billing for ESD I am billing three times EMR so I'm trying to achieve that if you are a surgeon and do an open colectomy it will be between $1,300 to $2,000 and for lap coli not big difference almost the same so you'll see here that still physician reimbursement for surgery is much higher although sometimes ESD spends the same time so what is the road ahead we need more perspective data from United States this data will convince the buyer to have to respect ESD and have it at least in their list but also we need to have the CPT code and very soon hopefully we'll hear about that and I think our societies are working that. Reaching out to ASGE, EGA and ECG to incorporate ESD in their management algorithm and guidelines are important that's why we got into EGA convincing to have practice update for ESD and I think it made a huge difference when that one got published also convincing our society to look and work on ESD code which I know they are working and ASGE is doing a great job with that and also making prospective trials comparing lap coli versus ESD and I know this could be a sensitive trial but we need this type of trial in United States. That's an example of the clinical practice updates so far we have two of them first one about utility of ESD in T1b esophageal cancer and the other one about the EGA and Institute endoscopic ESD in the United States. This one is more common I recommend adding it for all your predetermination package it will help with it and if you send it for any peer-to-peer and you tell them please refer to this page and you find that that's what our society recommend is very hard for them to argue with you. I would like to thank you and we'll open the discussion now for any questions. Thank you Dr. Altman for that excellent presentation and for sharing your experience with with the billing process and and all the importance of data I greatly appreciated that. The audience is ready with with questions for you but first just wanted to remind everyone the questions can be submitted by using the question box in the GoToWebinar panel on the right hand side of your screen and if you did not see the GoToWebinar panel please click on the white arrow on the orange box located on the right hand side of your screen. Our first question I know you mentioned that there is a learning curve, ESD learning curve. If we have any any fellows that are on the call today do you have any any advice for them at all? Yeah so for a fellow who are in fellows are interested in training in ESD I would say it may take more than one year so if you are going for an advanced in DOSC we fellowship I don't think within one year you'll be able to master EOS, ERCB and ESD but definitely you can have exposure for ESD and you can start doing animal labs for the first few years. If you ask me how many hours you should spend doing animals I would say minimum of 20 hours in animal labs and after that you may start going from exoplanet to live animals or if you are in a program that you can assist in life cases that would be even better. Just take the journey a little bit by little bit and slow. The worst thing you can do as a trainee is that you come out of fellowship, you're in your first job, you're in your first year and you do a procedure and you end up with a major complication and people establish certain reputation about you which is not true. So for someone who's coming out of fellowship I would say focus in improving your skill, focus in getting very good in EMR, also attend as many courses of ESD as you can. Once you are known, once people know about you, you have been there for six months at least then you can start venturing out and try to do something out of ordinary. I wouldn't recommend coming out of fellowship by the way and start practicing ESD unless you spend one year of dedicated training just for ESD which we do not have yet in the United States. Excellent, thank you. The other question is regarding the billing process. You shared your experience where you write a letter and then you explain what an ESD is and along with the letter you send the medical records and also the data with it. And then you also mentioned that if authorization is needed then you submit the voluntary predetermination request. Is that a difference between that and a prior authorization? Yes, so yeah that's a very important question. So prior authorization is more, it's almost like something you do before you do any procedure with any private insurance. You request their authorization and prior authorization is almost like a clerical thing. Usually the nurse or the office cleric will look at the code and approve it. But predetermination, you are telling them I would like a physician or someone to look at this procedure and determine that it is needed for the patient. So pre-authorization, you are authorizing this procedure based on a CBT code. Predetermination, you are saying I'm using unlisted code. If you get a pre-authorization, it's not guaranteed that you're going to get paid. If you have a predetermination, most of the time that's an approved case. You're going to get paid for that one. And most of my denial came when I only had pre-authorization but no predetermination. Okay, and the predetermination letter, does that work only with private institution or public as well? Yeah, so for public, you cannot do any of that. So if you work with Medicare, you cannot submit pre-authorization. You cannot submit predetermination. You can't submit everything after you do the procedure. So if it is private insurance, you can ask for voluntary predetermination. If it is insurance like Medicare, you cannot do any of that. You just do the procedure and hope that it will be accepted. Surprisingly, Medicare, they just pay less, but they do pay for these procedures. Okay, does adding the modifier code 22 to the code you use make any difference in terms of reimbursement at all? Yes, that's a good question. So modifier 22 is modifier for specialized service or service that took longer than anticipated. And modifier 22, you can add it to any code or any CPT code. I usually use modifier 22 with EMR. Or sometimes if you're going to do something like hybrid ESD and EMR, you can put modifier 22 with the hybrid technique. Having said that, modifier 22 requires documentation of why you chose that code. So you can say, for example, there was extensive fibrosis in the submucosa, which required that I spend 100 minutes dissecting this lesion or giving the complexity of the lesion and its location. I had to resort to using the specialized device, which led to that. So that language has to be there in the report to support the modifier 22. So just adding modifier 22 as a standard template would not be enough. And then if you use an unlisted code, does it usually trigger a pre-authorization letter or does it have to be a predetermination? So most of the time it could be pre-authorization, but a lot of times what happens is that once you use unlisted code, you're going out of the norm. So the clerk who are approving it, he's not going to approve it. So if you, for example, for the same lesion, use the CPT code that's there, like EMR code, it will just pass right away. Once you put unlisted code, he will have a hard stop. He cannot approve it, so he'll send it to the physician. Then the physician will review it. So instead of going every time through that and waiting for them to tell me that, I just from the beginning say, I'm submitting it for predetermination. I'm bypassing the first step. That makes sense. And the voluntary predetermination request, you mentioned it takes usually 15 to 30 days. Is there any way to expedite that process at all? Yeah, I have one case. In case of severe emergency, you can tell them and request to expedite it and you can request a quick peer-to-peer review. I had that done one time, but most of the time, unless you really have a strong reason that why you want to do it fast, you just have to wait. And there's also a pattern that when you work a lot with a certain private insurance, they know your name, they know you, they know you are doing that, and they will start to understand what you're doing. And you will do like one to two to three peer to peer review, and after that they know. They know that you are the guy who always go in and fight for this. And one time I had a patient that I told them, you know what, I'm going to let CNN know that you are not approving this and you want the patient to go for unnecessary surgery. And I got to another higher doctor. And by the way, if you got rejected in the peer-to-peer, you can always ask for something called a specialty peer-to-peer. So because whoever talked to you could be a general practitioner. They may not be a gastroenterologist. So you can say, no, I need a specialty peer-to-peer. And usually if it goes to the gastroenterologist, he will approve it. But unfortunately, this takes a lot of time and effort to do all the stuff. That's a good way to build relationships. Thank you for that. During your presentation, you mentioned the toolbox for tissue resection. Any preference on some of the tools that you use, stabilizing devices or tissue deposition devices that you're using in your practice? Yes. So for chronic ESD, given the lack of stability, there's two ways of doing it. You either do the bucket method, which is you go under the lesion, or you can use stabilizing devices. And the only one in the market is a double balloon device. And the double balloon device will help you to stabilize the lesion and perform ESD. And I would say I would use it for 70 to 80 percent of my procedures for chronic ESD. There's something I want to talk back about the insurance issue. Sometimes, and this happened to me here in Houston, that there is a health care system that some of the physicians start referring cases to me for chronic ESD. And that health care system, they own their insurance too. And they approach me and saying, we found that some of our physicians are sending you their colonic polyps that would otherwise would be sent for surgery. And they made it through the system to first consult me about these cases before they sent it to the surgeon because they discovered that there's cost saving. And I actually did not approach them about that. They just discovered it by themselves. So locally, you can do the same with your private insurance too. If you can demonstrate to the private insurance that you have a cost saving, they will tell the patient to come to you. And I have the same happening in my pancreas practice, that I will find patients showing up in my clinic and I ask them who referred you, and they say, my insurance told me to come to you. And you'll be surprised that the insurance now, they keep track of the diagnosis you are seeing. And they will say, for example, you are seeing, you are in the 90 percentile or highest 90 percentile in seeing colonic polyps or akalasia or pancreatitis. And when a patient requires referral, they will ask him to go to you. So in a way, building this relationship with insurance too will help. Wow. Any thoughts on having a bundled package for ESD negotiated with private insurance to cover both physician and hospital fees? Yes. So I tried that first for international patients because I also get some international patients for this procedure in Houston. We get many of these patients. And the problem with the package is that you need anesthesia to be on board. You need pathology to be on board. And also, you have to make it clear in the package that if complications happen and you're going to stay in the hospital, that would be outside the package. And that's a problem doing it for chronic ESD. I was successful doing that for screening colonoscopy. So I created for our international patient a package for screening colonoscopy. When we tried to do it for chronic ESD, my hospital was very reluctant, given that once you are seeing a package, people expect, like, is the hospital stay? Like, let's say you did chronic ESD. Now you want to admit the patient for OMS. Is this part of it or not part of it? And it became very hard. But I think once we apply for a code and we'll have a CPT code, I think having one night to stay will be part of that and it will be covered with it. That's great. And I appreciate you sharing some of the data that ESD reimbursement in the United States. Are you seeing or do you have an experience with data outside of the United States for reimbursement for this type of procedures? Yes. So the best system for ESD would be the Japanese healthcare system. And they have been doing ESDs now since 2002. And they mainly do it as a part of their effort to decrease gastric cancer. So the ESD reimbursement there is very high. And when you see the Japanese endoscopist, they only do two ESD a day. So the professor will do one and then go to his office in the afternoon to do another one. And they spend their time and other doctors will be there doing another ESD. So it is well reimbursed in Japan. Outside of Japan, I would say even in China, it is still almost like China is a government healthcare system. If you are in a big hospital, you'll be doing large volume ESD. Smaller hospital, they will not have the ESD at all. In Europe, it's not clear yet. Like in England, they are barely developing their ESD programs. It's available in a few hospitals there. And the rest of Europe and other countries, it's almost like patient has to pay for it. And in some of the Latin American countries, patient will pay for the knife cost before they start the procedure. So you will pay for the physician cost and also pay for the equipment cost before you do the procedure. So it's totally variable between one country and another. Do you think we'll get CPT code soon? Yeah, we hope that by 2023 or 2024, we will have a code. I think we generated enough data now in the United States. Dr. Peter Dragunov, I, and another four or five physicians, we just had our prospective registry of more than maybe 1,000 ESD done in the United States. We also have a prospective registry for chronic ESD for procedure done using Lumandy double balloon device. And we have around 200 prospective patient done with that that will be published very soon. And so once all this data come out, there will be enough evidence that we should have a CPT code in the United States. I'm looking forward to that. Going back to the predetermination letter, do you typically mention the RVU or the cost at all when you sent that? So when we send this letter to the insurance, we just say the word that this procedure will save the patient invasive surgery. Our alternative for this procedure is right hemocolectomy. And I make sure or left hemocolectomy or esophagectomy. And I make sure that I put that in the letter. I don't say cost saving. I just write the alternative and only put the name of the surgery and become a little bit like too much. And by the way, the same happened with pump or oral myotomy. It used to be rejected all the time. And UnitedHealthcare starting this October, they approved it. And part of them approving it that many physician were complaining. And I had a meeting with UnitedHealthcare like one year ago, and I told them it doesn't make any sense that you push patient to have heteromyotomy while they can have endoscopy. And we start to use even another upper myotomy code, which is a CPT code. And they say you just will approve it. But of course, this is not the right code for it. But all of a sudden, because of all the pressure, in October of 2020, they start approving POM as a treatment, because their guideline we're saying POM is experimental. For ESD, it's not like that because most of this patient have tumors and lesions, and they don't argue much with it. So in fact, I would say my peer to peer always go well for ESDs. Sometimes it is harder for per oral myotomy for akinesia. Dr. Othman, thank you so much for being being here with us tonight. Before we close, any final thoughts that you'd like to leave the audience with? Yeah, I just want to tell them that in addition to learning the technical skill, just be aware that the process of doing ESD involve working very well with your team, with your hospital, with the healthcare system and the insurance and also the referring physician. And understanding all of this will enable you to have a successful ESD program. Dr. Othman, thank you so much for sharing your experience here with us tonight. I greatly appreciate it. And as a final reminder, please do check ASGE's calendar of events, as we will continue to feature relevant sessions to our Thursday night light series. Also, I would like to take a moment to thank our corporate supporters for their contributions for making these events happen. Our next webinar will be next Thursday, January 21 at 7pm, presented by Dr. Chris Thompson from AIDE on endoscopic sleeve gastroplasty. And in addition to our Thursday night webinars, we also plan to host events at various times to accommodate our audience around the world. In closing, Dr. Othman, thank you again for this excellent presentation, which was brought to you by Lumendi. For Lumendi's latest technological developments around the challenges facing healthcare providers and patients, please do visit lumendi.com. Finally, I want to also thank you for your participation tonight. We hope this information has been useful to you and your practice. And with this, this concludes our presentation. Thank you again.

webinar

reimbursement

complex endoscopic resection

American Society for Gastrointestinal Endoscopy

Dr. Mohamed Othman

endoscopic submucosal dissection

billing process

ESD procedures

future of ESD

CPT code