ASDIN 10th Annual Scientific Meeting Final

Transcription

1 Cost Saving Techniques for Outpatient Vascular Access Centers ASDIN 2014 Annual Meeting Phoenix, AZ Jeffrey Hoggard MD FACP FASN Capital Nephrology Associates Raleigh, NC Conflicts of Interest Medical director for Fresenius Vascular Care and Fresenius Medical Care Bard- principle investigator and consultant CryoLife- consultant Teleflex consultant Objectives Overview of SGR formula and 2014 CPT Fee Schedule and Coding changes that will impact finances in the outpatient access centers Identify cost saving strategies in the outpatient center - coding expertise - efficient procedure planning - smart shopper/ supply costs SGR: Sustainable Growth Formula Balanced Budget Act 1997 Linked medicare spending for physician services to GDP Flawed economic formula Yearly temporary fixes to avoid drastic double digit reductions in payments SGR: Sustainable Growth Formula Congress passed bill 12/18/13 delaying the 26% medicare reimbursement cut until March 31,2014. Currently there is a bill which proposes : - full repeal of the SGR formula -0.5% payment increase ( CMS ) for next 5 years - no agreement on how to fund $125 B - no agreement on what new formula will be ( likely value based payment system) SGR Repeal and Medicare Provider Payment Modernization Act (H.R.4015/S2000) beginning in 2018 : new merit-based incentive payment system (MIPS) consolidate three existing incentive programs: Physician Quality Reporting System Value-Based Payment Modifier Meaningful use of electronic health records 1

2 SGR Repeal and Medicare Provider Payment Modernization Act (H.R.4015/S2000) Join RPA Write your Congressman 2014 CPT Fee Schedule Proposed 10.4 % reduction in revenues Actual ~6% reduction - Outpatient center impact will depend on payor/procedure mix - Does not include cost increases due to inflation CPT Fee Schedule Angioplasty/Thrombectomy codes reduced 3-4 %(vs 10%) Stent codes reimbursement reduced by 20-24% (angioplasty will be bundled) Catheter codes reimbursement reduced by 7% vs ( 3%) 2014 CPT Fee Schedule Coil embolization increased by 193% PAD codes reduced by 6% ( vs 38% proposed) 2014 CPT Fee Schedule : Stents For 2014, intravascular stent codes 37205, and have been deleted. New Stent codes have been created Transcatheter placement of intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel when performed; each additional artery Initial vein each additional vein These codes bundle angioplasty, and radiological supervision and interpretation. Catheterization is not included and can be separately reported. Stents cannulation and angiogram stent placement ( venous stent) S and I Venous angioplasty S and I 24% reduction ( $1450 ) 2

3 Stent Caveats Any angioplasty performed outside of the fistula /graft zone is separately billable. Angioplasty and Thrombectomy No changes to actual CPT codes. Practice expense RVU and work RVU were revised and overall reimbursement is down. Venous angioplasty( 35476;75978) -3% Arterial angioplasty( 35475;75962) -3% Thrombectomy ( 36870) -4% Catheters No change to the CPT codes. Reimbursement is down due to significant reduction in fluoroscopic guidance code(77001)(-34%) Coils Transcatheter embolization (37204) Uterine fibroid embolization (UFE) DELETED DELETED Insertion(36558) -7% Exchange( 36581) -7% PD catheter insertion( 49418) -4% 4 NEW CODES have been created based on the vessel being treated and the reason Coils Vascular embolization or occlusion, inclusive of all radiological supervision, intraprocedural road mapping, and imaging guidance necessary to complete the intervention, VENOUS,.. UFE Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention, for tumors, organ ischemia or infarction Arterial 3

4 Bleeding Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation Accessory vein embolization angiogram of fistula st order venous catheterization coil coil ( vein) S and I follow-up imaging Increase of 193% PAD No changes to the CPT codes. Overall interventions are down by 6% and diagnostic arteriograms down by 4%. Fem/Pop PTA ( 37224) -6% Fem/Pop stent ( 37226) -6% Fem/Pop atherectomy ( 37225) -6% Aortogram with bilateral runoff -4% Cost Saving Strategy #1: Coding - Critical to optimizing reimbursement - Must have expert knowledge of coding rules - ICD -10 begins Oct Strategy #2: Planning and Staging Review of prior interventions and physical exam: size and placement of sheath Staging of procedures: immature fistulas refractory stenoses/lesions, multiple lesions Sterile packs Contrast Needles Sheaths Wires Balloons Strategy #3: Smart Shopping Thrombectomy tools 4

5 Sterile Packs - $40-50 range - Includes : drapes, gowns, towels sterile C-arm and radiation shield covers bowls, syringes, needles disposables ( scissors, scapel, hemostat) labels Contrast Consider Omnipaque( iohexol) or Oxilan (loxilan) for routine ( $4-10/50ml bottle) Consider iodixanol (Visipaque)( $20-30/50ml bottle) for patients with documented contrast allergy Safety First Use generics Sutures Access Needles 18 ga angiocath 18 ga thin walled needle Mini-stick // Micropuncture 18 ga. angiocath 18 ga thin wall needle $2 $2 5

6 Micropuncture / Mini-stick Sheaths $18-45 Cordis Avanti $6/sheath Sheaths Sheaths Cordis Brite Tip $8.50/sheath Terumo Wires Bentson( non-hydrophilic) $6-8 Amplatz( super stiff) $12-14 Glide wire ( hydrophilic) $18-30 Angioplasty Balloon issues RBP- high pressure vs ultra-high pressure Profile Shaft length Trackability platforms more specific to arterial work Road runner ( hydrophilic) $

7 Angioplasty Balloons Balloon inflation devices Ultra-high pressure balloon Conquest/Atlas $ High pressure balloon $ Arterial balloons $ Balloon Inflation Devices Hand inflation with acrylic syringe ( Medallion- Merit) ( $2-4) Inflation device with pressure gauge ( $25-45) Stents Bare Metal Stent $ Covered stents $ Thrombectomy devices: Angiojet PTD: Treretola device $ /catheter $ /device 7

8 The Cleaner Thrombectomy devices Mach 1 aspiration catheter $ / device $60-80 Fogarty Embolectomy Balloons Summary Must know how to correctly code procedures ( including appropriate documentation of the work). Planning of the procedure facilitates more cost efficient use of supplies. Staging procedures can be beneficial. Cost comparison of supplies is appropriate as long as safety and effectiveness is maintained by the operator. $50-75 Summary Fixed costs ( rent and overhead) and personnel costs are going up while reimbursement continues a downward trend If your center cannot increase the number of procedures and no further cuts is supply costs are evident, consider : 1. partnering with one of the national access companies 2. expansion of procedures types (Ports, PAD, veins) Recommendation ASDIN List Serv : Tell other members about your cost saving techniques Don t forget to join RPA and write you Congressman 8

9 Thank You! Questions 9