Office Injectables, Lasers, Balloons: Options and Reimbursement UCLA Laryngology Update 2016 April 15, 2016 Jennifer Long, MD, PhD and Michael Holliday, MD UCLA Voice Center for Medicine and the Arts
Conflicts of Interest None Disclaimer Reimbursement data generated from Medicare Physician Fee Schedule search https://www.cms.gov/apps/physician-feeschedule/overview.aspx
Outpatient billing for office procedures Reimbursement depends on the office setting: Hospital-based outpatient facility Free-standing clinic Ambulatory Surgery Center (as licensed by Medicare) J-codes HCPCS for non-orally administered medications C-codes HCPCS for procedural devices under Hospital Outpatient Prospective Payment System HCPCS codes are used to track the overall costs of hospitalbased outpatient services. Sometimes but not always reimbursed.
Outpatient billing for office procedures Modifier 25 for a significant, separately identifiable E/M service, above and beyond the usual pre- and post- care for the procedure. Mod 25 applies to the E/M visit, NOT to the procedure
Injectables Chemodenervation (e.g. Botox) Fillers Gels Calcium hydroxyapatite Hyaluronic acid Micronized Alloderm Lasers Potassium Titanyl Phosphate (KTP) Pulsed Dye Laser (PDL) Balloons
Chemodenervation Botulinum Toxin Inhibits acetylcholine release at the neuromuscular junction 7 antigenically distinct subtypes (A-G) Vary in potency and duration of effect Manufactured by Clostridium botulinum fermentation Purified to a complex consisting of the neurotoxin and several accessory proteins
Botulinum Toxin Type A BOTOX (onabotulinumtoxina), Allergan Introduced in US in 1989, reformulated in 1997 100 unit vial Dysport (abobotulinumtoxina), Galderma In US since 2009 300 unit vial Diffuses more so may be better for aesthetics than larynx XEOMIN (incobotulinumtoxina), Merz 50, 100, and 200 unit vials Increasingly used due to lower cost Similar to Botox but without attached proteins
Botulinum Toxin Type B MYOBLOC (rimabotulinumtoxinb) Injection, Solstice Neurosciences Used for resistance/intolerance to toxin A 5000 units/ml Shorter lasting ph 5.6 (may sting on injection)
Chemodenervation Reimbursement CPT Code Procedure CMS Reimbursement 64616 Chemodenervation of muscle, neck, dystonia 64617 CHEMODENERVATION OF MUSCLE; LARYNX, UNILATERAL, PERCUTANEOUS, +/-EMG 31570 Laryngoscopy with vocal cord injection $130 $200 $350
Botulinum Reimbursement HCPCS code J0585 J0588 Injection, OnabotulinumtoxinA (Botox) Injection, IncobotulinumtoxinA (Xeomin) Previously $25/Unit
Botulinum storage and use Use within 24 hours after reconstitution Single-use vials
Injectable Fillers Objective to mechanically fill glottic incompetence due to: Vocal fold paralysis Vocal fold paresis Presbylaryngeous / Vocal fold atrophy Scarring
Injectable Fillers: Gels Prolaryn Gel (formerly Radiesse Voice Gel) Aqueous glycerin/carboxymethylcellulose gel Merz North America, Inc 1mL resorbs within 3-6 months Renu Gel Regen Scientific Aqueous glycerin/carboxymethylcellulose 2-year shelf life $184 / 1.5 ml 10-14 weeks
Injectable Fillers: CAHA Implants Implant: Calcium hydroxyapatite (CAHA) microspheres in gel carrier Long-term: 12-18 months Prolaryn PLUS (Formerly Radiesse VOICE) Merz 1mL Renu Voice Regen Scientific $203 per 1.5mL
Injectable Fillers: Hyaluronic Acids Naturally occurring substance in lamina propria Intermediate-term: 4-6 months Not FDA-approved for larynx Options: Juvederm (Allergan) Restylane (Galderma)
Collagenous Injectables Bovine-based gelatin: Gelfoam, Surgifoam Requires reconstitution, resulting in viscous substance Uses 18G needle for injection Collagen Bovine: Zyplast no longer available Human: Cymetra (micronized Alloderm)
Injectable Reimbursement CPT Code Procedure CMS Reimbursement 31570 Laryngoscopy, Direct, inj vocal cord (office and OR) $350 31571 Microlaryngoscopy with injection (OR only) 31599 Larynx surgery, unlisted Contracted C1878 Material for vocal cord medialization
In-Office Lasers Indications Laryngeal papillomas Dysplasia, Carcinoma in Situ Leukoplakia Granulomas Polypoid corditis/reinke s edema Ectasias and Varices
Thalassa Medical 2011 In-office Laser Options Two mainstay angiolytic lasers 585-nm Pulsed Dye Laser (PDL) Oxyhemoglobin absorption peak of 577nm 532-nm Potassium Titanyl Phosphate (KTP) Oxyhemoglobin absorption peak of 542nm
In-office Laser Options 532-nm KTP AuraXP Boston Scientific/AMS/Laserscope Solid state KTP crystal less maintenance Exposure duration: 0.1ms to continuous Pulse rates: 1 to 10 pulses per second Plug-and-play Retail price $90,000
In-office Laser Options Two fiber options disposable, single-use EndoStat Fiber, 0.4mm x 12 (KTP/YAG) $380.00 EndoStat Fiber, 0.6mm x 12 (KTP/YAG) $399.00 Requires sheath to protect channel (limits suction strength) 0.4mm with more concentrated beam and more maneuverable (less resistance between sheath and fiber)
In-office Laser Options 585-nm PDL PhotoGenica V (Cynosure, Inc) Liquid energy medium: requires dye changes Reports of increased vessel wall disruption and bleeding due to short pulse width Limited fiber options 0.6mm Damaging to channeled laryngoscope without sheath No longer available Zeitels SM, et al. Ann Otol Rhinol Laryngol 2006; 115:679-85
Laser Reimbursement CPT Code Procedure CMS Reimbursement 31599 Larynx Surg Procedure Unlisted KTP-laser ablation of lesions *** EndoStat Fiber, 0.4mm $380.00 EndoStat Fiber, 0.6mm $399.00
KTP vs PDL Zeitels SM, et al. Ann Otol Rhinol Laryngol 2006; 115:679-85). Koufman JA, Rees CJ, Frazier WD, Kilpatrick LA, Wright SC, Halum SL, Postma GN. Unsedated, officebased laryngeal laser surgery: review of 443 cases using three wavelengths. Presented at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Toronto, Canada, September 19, 2006, and submitted for publication to Otolaryngology-Head and Neck Surgery).
Balloon dilators For esophageal stenosis especially in laryngectomees Require 2.8 mm channel to pass through scope Boston Scientific CRE, Cook Quantum, Olympus Swift Fixed wire or wire-guided for fluoroscopy
Balloon dilation Reimbursement CPT Code Procedure CMS Reimbursement 43220 Esophagoscopy, flexible, with dilation $1151 C1726 Catheter, balloon dilation
Outpatient Reimbursement Medical devices and drugs are a significant cost burden in outpatient procedures. Typically not Medicare-reimbursed. Private insurers vary. Options for non-hospital services: Patient pays out of pocket for device/drug Clinic absorbs cost Petition payors for fair reimbursement