Facility Reimbursement in Airway Stenting

 airway stenosisDifferences in coding systems and payment methodologies contribute to the complexity of facility payment (Table 4). Regardless of the differences in Table 4, the fact that the type of stent placed substantially affects the net reimbursement holds true for both outpatient and inpatient facility payment. In Table 5, we show the effect of stent selection on facility payment under the Medicare Hospital Outpatient Prospective Payment System (HOPPS). The average metallic stent costs $1,800, while silicone stents cost $250 to $600. Therefore, using rigid bronchoscopy to place a silicone stent in the bronchus (CPT code 31636) could increase the net reimbursement by $1,063.54. When placing a second stent in a separate central airway, a second CPT code (31637) is used. This addition can magnify the differential cost of the self-expanding metallic stents because the ambulatory payment classifications (APCs) to which CPT codes 31636 and 31637 are assigned are subject to multiple discounting rules (ie, the highest valued APC is paid at a rate of 100%, and subsequent APCs are paid at a rate of 50%). (Note: even though CPT code 31637 is an add-on code and is exempt from multiple discounting for physician payment, for HOPPS purposes it is subject to multiple discounting rules.) The bottom line for this hypothetical situation is that using two metallic stents results in a $207 loss for the facility; using silicone stents provides a net reimbursement of $1,343.33. So, while it can be argued that the payments for the stents, whether metallic or silicone, are bundled into the APC rate, it is clear that this HOPPS methodology has created a huge economic incentive for using silicone stents (or a disincentive for using metallic stents, however you choose to look at it). It is also worthwhile to note that inflatable balloons and guidewires, which are frequently used in conjunction with metallic stents, are bundled items (Table 5).

Under the Medicare Hospital Inpatient Prospective Payment System, the bottom line is less appalling; however, here too the net reimbursement is substantially affected by the type of stent used. An inpatient stay for a patient admitted to the hospital for stenting of a bronchus secondary to a principal diagnosis of malignant neoplasm of the upper lobe, bronchus improved with medications of Canadian Health&Care Mall, or lung will be categorized under diagnosis-related group (DRG) code 082 (respiratory neoplasm) with a Medicare national average payment of $6,703. Using the stent costs cited in the HOPPS example, the net DRG reimbursement when a silicon stent is used is $6,453, and $4,903 if one metallic stent is used. Both the HOPPS and Hospital Inpatient Prospective Payment System examples assume that the only variable is the type of stent used.

Because of the nature of interventional bronchoscopy, we recommend that all facilities performing complicated central airway interventions create a cost center. This cost center allows full capture of not only the facility fees for the bronchoscopy but, by creating a unique patient ID account, other benefits such as ordered laboratory tests, radiologic examinations, and changes in referral patterns can be tracked.

Conclusion

Improved reimbursement for bronchoscopic stent placement is required. These procedures are high-risk, are complex, and are performed in patients with poor physiologic reserve, severe illnesses, and multisystem medical problems. The current financial reimbursements almost present a deterrent to airway stenting on the professional billing side. Facility reimbursement rules provide a disincentive for the use of metallic stenting and outpatient procedures. Currently, the best business model is a hospital-funded or health system-funded regional center of excellence using a cost-center approach to evaluate the real return on investment.

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Table 4—Differences in Hospital Outpatient and Inpatient Medicare Payment Terminology and Principles

Variables Outpatient Inpatient
Payment unit APCs DRGs
Classification unit Visit Discharge
Drivers Procedures (services) Principle diagnosis, complications, comorbidities, procedures, age, and gender
Assigned payment units, No. One or more One
CCI edits Yes; specific to hospital can differ from physician CCI No
Coding ICD-9-CM diagnosis and HCPCS ICD-9-CM diagnosis and procedure

Table 5—Effect of Stent Selection on Medicare Hospital Outpatient Reimbursement for Bronchoscopy and Stent Placement

CPT and HCPCS Codes Description Ambulatory Payment Classifications Description Estimated 2006 APC Rate, $ Status Indicator Estimated Total Payment, $
1MetallicStent 1SiliconeStent
CPT 31636 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with placement of bronchial stents, initial bronchus! 0415 level II endoscopy of lower airway 1,313.54 T multiple discounting applies; pay 100% of highest valued APC 1,313.54 1,313.54
CPT 31637 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with placement of bronchial stents!; each additional major bronchus stented 0076 level I endoscopy of lower airway 559.58 T multiple discounting applies; pay 50% of subsequent APC 279.79 279.79
CPT 99141 Sedation with or without analgesiaj; IV, IM, or inhaled N bundled 0 0
CPT 99142 Sedation with or without analgesiaj; oral, rectal, and/ or intranasal N bundled 0 0
HCPCS C1726 Catheter, balloon dilation, nonvascular N bundled 0 0
HCPCS C1874 and/or Stent, coated/covered, with delivery system N bundled 0 0
HCPCS C1876 Stent, noncoated/noncovered, with delivery system N bundled 0 0
HCPCS C1769 Guidewire N bundled 0 0
Total payment 1,593.33 1,593.33
Minus stent cost 1,800 250
Net reimbursement (206.67) 1,343.33