The Changing Face of Outpatient Bronchoscopy in Scott Manaker, MD, PhD, FCCP ; and Anil Vachani, MD, MSCE

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1 CHEST Commentary The Changing Face of Outpatient Bronchoscopy in 2013 Scott Manaker, MD, PhD, FCCP ; and Anil Vachani, MD, MSCE In 2013, the outpatient hospital payment from Medicare for a transbronchial needle aspiration more than doubled. At the same time, the recently updated American College of Chest Physicians guidelines for the diagnosis and management of lung cancer now recommend needle techniques, such as transbronchial needle aspiration, over surgical staging. The convergence of these two events will accelerate the existing forces of technology and economics that have been influencing both the practices of outpatient bronchoscopy and mediastinoscopy and the management of patients with lung cancer over the past 20 years. CHEST 2013; 143(5): Abbreviations: APC 5 Ambulatory Payment Classification; CPT 5 Current Procedural Terminology; EBUS 5 endobronchial ultrasound; NCD 5 national coverage determination; TBNA 5 transbronchial needle aspiration On January 1, 2013, the outpatient hospital payment from Medicare for transbronchial needle aspiration (TBNA) more than doubled, rising by. $800 over the 2012 reimbursement ( Table 1 ). 1-3 TBNA (along with bronchoscopy for balloon occlusion) has moved from the lower reimbursing Ambulatory Payment Classification (APC) 0074 for diagnostic bronchoscopy to the higher reimbursing APC code 0415 for therapeutic bronchoscopy ( Table 1 ). This move of TBNA to APC 0415 is coupled with a 23% decrease in payments from Medicare for APC 0415 as part of the annual rebasing of the hospital outpatient prospective payment system to achieve budget neutrality. 2 This annual adjustment consequently lowers the reimbursement of all other therapeutic bronchoscopic procedures while increasing payments for TBNA. Parallel changes in outpatient hospital bronchoscopy payment will likely occur from other payers to the Manuscript received January 9, 2013; revision accepted January 12, Affiliations: From the Department of Medicine, University of Pennsylvania, Philadelphia, PA. Funding/Support: This work was funded, in part, by the Pennsylvania Department of Health [Grant ]. Correspondence to: Scott Manaker, MD, PhD, FCCP, Department of Medicine, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, 8 Penn Tower, Ste 800, One Convention Ave, Philadelphia, PA ; scott.manaker@uphs.upenn.edu 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: /chest extent that facility contracts with private insurers reflect changes in Medicare payment rates. Such large changes in reimbursement raise several possibilities about the future use of endobronchial ultrasound (EBUS), TBNA, and other therapeutic bronchoscopy procedures in APC The increase in reimbursement for TBNA may motivate additional outpatient facilities to provide TBNA, further disseminating this technology and leading to an appropriate increase in the use of TBNA for the evaluation of thoracic disease. Alternatively, this increase could produce adverse consequences, such as an acceleration of inappropriate TBNA procedures and associated contribution to the rising costs of health care. 4 Regardless of the propriety, increases in TBNA will likely accentuate the reduction in mediastinoscopies observed over the past 5 years ( Fig 1 ). 5 The primary role of TBNA has evolved, and now plays a central role in the evaluation of patients with potential malignancy. 6-8 This evolution occurred upon a backdrop of extraordinary change in the clinical care of such patients over the past 20 years. Before 1990, patients with an abnormality on their chest radiograph were followed with serial routine radiographs, often supplemented with CT scans or surgical lung biopsy specimen or mediastinoscopy evaluation. Worrisome growth of abnormalities demonstrated radiographically typically prompted proceeding with surgical biopsy. For the next 2 decades, advances in chest CT imag ing, TBNA, transthoracic needle aspiration, video-assisted thoracic surgery, PET scanning, bronchoscopic imaging Commentary

2 Table 1 CPT Codes Assigned to Bronchoscopy APCs for 2012 to 2013 With Corresponding Base Payment Rates Bronchoscopy APC APC 0074 level 1 lower airway endoscopy $ $ , diagnostic bronchoscopy 31622, diagnostic bronchoscopy 31623, bronchoscopy with brushings 31623, bronchoscopy with brushings 31624, bronchoscopy with BAL 31624, bronchoscopy with BAL 31645, initial therapeutic aspiration bronchoscopy 31645, initial therapeutic aspiration bronchoscopy 31646, subsequent aspiration bronchoscopy 31646, subsequent aspiration bronchoscopy 31625, bronchoscopy with endobronchial biopsy 31625, bronchoscopy with endobronchial biopsy 31628, bronchoscopy with transbronchial biopsy 31628, bronchoscopy with transbronchial biopsy 31632, transbronchial biopsy in an additional lobe 31632, transbronchial biopsy in an additional lobe 31629, transbronchial needle aspiration 31633, transbronchial needle aspiration in an additional lobe 31634, balloon occlusion bronchoscopy 31635, foreign body removal bronchoscopy 31635, foreign body removal bronchoscopy 31643, brachytherapy bronchoscopy 31643, brachytherapy bronchoscopy 31656, bronchoscopic bronchography APC 0415 level 2 lower airway endoscopy $2, $1, T, bronchial valve insertion 31647, bronchial valve insertion 31651, bronchial valve insertion, each additional lobe 0251T, bronchial valve removal 31648, bronchial valve removal 31649, bronchial valve removal, each additional lobe 0276T, bronchial thermoplasty, one lobe 31660, bronchial thermoplasty, one lobe 0277T, bronchial thermoplasty, two or 31661, bronchial thermoplasty, two or more lobes more lobes 31640, bronchoscopic tumor excision, 31640, bronchoscopic tumor excision, any method any method 31641, laser bronchoscopy 31641, laser bronchoscopy 31630, bronchoscopy with balloon dilation 31630, bronchoscopy with balloon dilation 31626, bronchoscopy with fiducial marker 31626, bronchoscopy with fiducial marker placement placement 31629, transbronchial needle aspiration 31633, transbronchial needle aspiration in an additional lobe 31634, balloon occlusion bronchoscopy 31631, tracheal stent placement 31631, tracheal stent placement 31638, any (tracheal or bronchial) stent revision 31638, any (tracheal or bronchial) stent revision 31636, bronchial stent placement 31636, bronchial stent placement Note the significant change in facility payments associated with the shift of transbronchial needle aspirations and balloon occlusion bronchoscopies from APC 0074 to APC 0415 in In 2013, CPT for bronchoscopic bronchography was deleted and should be reported with the unlisted code Also in 2013, CPT created to and to replace 0250T and 251T; and created and to replace 0276T and 0277T, respectively. APC 5 Ambulatory Payment Classification; CPT 5 Current Procedural Terminology. with EBUS, endoscopic ultrasound with fine needle aspiration of mediastinal lymph nodes, and navigational bronchoscopy all led to iterative changes in the diagnosis and staging of thoracic malignancies. Since 2011, the potential for low-dose chest CT scan screening to evaluate patients at high risk for lung cancer may lead to increased use of many of these diagnostic modalities. 9 The initial dissemination and integration into clinical practice of many of these technologies has been delayed both by the time necessary to develop appropriate Current Procedural Terminology (CPT) codes to report these services to payers 5,10-12 and by adverse coverage determinations. For example, although PET scanning was developed in the early 1990s, the first national coverage determination (NCD) by Medicare did not occur until 1999, effective retrospectively to January 1, 1998, and limited PET scanning to the evaluation of solitary pulmonary nodules and the initial staging of non-small cell lung cancer. 13 Expansion of the NCD to restaging in patients with non-small cell lung cancer lagged until Some payers did not cover EBUS until 2011, 14 and many still fail to cover navigational bronchoscopy because it is considered experimental, investigational, or unproven. 15 Despite support from a multispecialty society coalition advocating the integration of low-dose CT screening into clinical practice, 16 neither an NCD from Medicare nor a ruling from the US Preventive Services Task Force has been issued. With the delays in integrating technological advances into routine clinical practice conferred by the reimbursement and coverage processes, the increase in EBUS use did not begin until 2005, when coverage for EBUS was initiated 5 ( Fig 1 ). For the initial 3 years journal.publications.chestnet.org CHEST / 143 / 5 / MAY

3 Figure 1. Medicare-paid claims by calendar year. For EBUS, navigation bronchoscopy, and TBNA, paid Medicare claims data begin in the calendar year following development and publication of a Current Procedural Terminology (CPT) code. CPT codes for each procedure are as follows: TBNA, 31629; TBNA, second lobe, 31633; EBUS, 31620; navigational bronchoscopy, 31627; and mediastinoscopy, EBUS 5 endobronchial ultrasound; TBNA 5 transbronchial needle aspiration. after the 2005 implementation of CPT code for EBUS, 10 Medicare allowed a transitional pass-through payment to an outpatient hospital facility for each bronchoscopy that included performance of EBUS. 17 The initial payments of $1,731 in 2005 rose to $1,985 by ,19 Following expiration of this transitional pass-through payment and packaging of EBUS as intrinsic to the underlying base bronchoscopy in 2008, 20 no separate payment occurred for EBUS; rather, an additional $49 was added to each of the diagnostic bronchoscopies in APC 0074, regardless of whether EBUS was performed. Such payment policy increased reimbursement for all diagnostic bronchoscopies in APC 0074 and obliterated any financial incentive for excessive or inappropriate use of EBUS; the bronchoscopist could use EBUS during bronchoscopy as clinically appropriate. Even after expiration of the transitional pass-through payment, EBUS use continued to increase rapidly between 2008 and ( Fig 1 ). Clearly, prior fears that falling facility reimbursement would reduce EBUS have not come to pass. 5,19 Coupled with this persistent, steep increase in the number of bronchoscopies performed that incorporate EBUS (and TBNA), there has been a slow, but steady fall in the number of mediastinoscopies ( Fig 1 ). The most current Medicare data from 2011 revealed that the use of mediastinoscopy has fallen by. 25% from the peak in 2005, and these data pose many unanswered questions. 5 Whether the reduction in mediastinoscopy noted in the Medicare population is attributable solely to cases diagnosed or staged from a bronchoscopic procedure remains unknown. Although mediastinoscopy has traditionally been considered as the gold standard staging procedure in clinically appropriate cases, 21 several studies suggested that imaging-guided bronchoscopic biopsy confers an equivalent diagnostic yield with fewer complications in patients with malignancy 7,22-25 and may lead to a lower rate of noncurative resection. The increasing importance of histologic subclassification and acquisition of sufficient diagnostic material to allow for molecular testing will further fuel this controversy. Although most easily accomplished through a surgical approach, recent evidence suggests that these important modern diagnostic tasks are successfully performed in the majority of cases that use cytologic material obtained with bronchoscopy. 26 It is also unclear whether parallel reductions in mediastinoscopy performance rates will occur in non- Medicare populations, especially in light of delayed coverage by other payers for imaging-guided bronchoscopy.14,15 Arguably, the most important question may be the comparative cost-effectiveness of mediastinoscopy vs imaging-guided bronchoscopy in diagnosing and staging intrathoracic malignancy. 27,28 Converse to the experience with EBUS, the 2013 changes in facility reimbursement could affect the use of a large number of diagnostic and therapeutic bronchoscopic procedures. The new facility reimbursement rates are not anticipated to lead to changes in the total expenditures for bronchoscopy because the expected volumes of each bronchoscopic procedure are calculated into the payment rate for each APC; that is, the fall in reimbursement for each procedure assigned to APC 0415 will be offset by the increase in the volumes of that APC occurring from the movement of TBNA to APC Likewise, the small increase in the outpatient hospital payment for APC 0074 should accommodate the fall in volume of APC 0074 by the departure of TBNA. 2 The 23% fall in reimbursement for APC 0415 for calendar year 2013 ( Table 1 ) might engender fear that patient access to medically necessary, advanced therapeutic bronchoscopic services will be severely curtailed. Such fears would echo the outcry within the pulmonary community in 2008, when the transitional pass-through payment for EBUS expired. 19 Fortunately, the steady growth of EBUS (and TBNA) over the past several years, 5 despite the fall in reimbursement in 2008, portends no adverse impact on the use of lasers, stents, and other advanced therapeutic bronchoscopies in APC 0415 that resulted from the decrease in facility reimbursement for these procedures. Furthermore, the reimbursement (both technical revenues, such as APC payments, to facilities and professional fees to physicians) for the families of both diagnostic bronchoscopies in APC 0074 and advanced therapeutic bronchoscopies in APC 0415 represents a small fraction of the overall revenues generated in the care of patients with thoracic 1216 Commentary

4 malignancies.5 The economic incentives for a robust interventional pulmonology program lie within the downstream revenues accruing to a facility for the disease-state care of these patient populations. 29,30 An additional consideration of the 2013 reimbursement change centers on whether the increasing rate of EBUS performance will remain constant, or further accelerate. 5 Because TBNA is increasingly performed with EBUS guidance, any incentives for increased TBNA use, whether clinical or economic, will also drive further use of EBUS. Independent technological drivers of EBUS use, such as the performance of peripheral EBUS with navigational bronchoscopy or during fiducial placement, will also affect future EBUS volume. Certainly, the addition of CPT code for navigational bronchoscopy 11 will stimulate EBUS performance in elderly patients because Medicare currently covers this service ( Fig 1 ). 5 However, payment policies from numerous other payers that currently withhold reimbursement for navigational bronchoscopy may sharply curtail this impact in other patient populations. 15,31-34 The most uncertainty regarding the 2013 outpatient hospital reimbursement schedule centers on the impact on TBNA performance volumes. Novel forms of reimbursement, including bundled payments, shared savings, and accountable care organizations 35,36 designed to improve quality and reduce total health-care expenditures, will facilitate the potential allocation of windfall reimbursement accruing from TBNA at facilities to physicians. Certainly, these economic considerations risk inappropriate performance of TBNA akin to data suggesting the inappropriate performance of cardiac catheterizations and cardiac stress testing as a consequence of financial incentives to perform these procedures.37,38 In fact, the seemingly inappropriate use of cardiac stress testing is greater when performed by physicians who billed for both the professional and the technical fees as a consequence of office-based procedures. 39 In parallel to the change in facility-based reimbursement for TBNA, the recent update of the American College of Chest Physician guidelines on lung cancer staging recommends the use of needle techniques (EBUS-TBNA, endoscopic ultrasound with fine needle aspiration, or both) over surgical staging as the best first test. 40 Both the increased reimbursement for TBNA and the new guideline recommendations will lead to continued growth of needle techniques for the diagnosis and management of known or suspected lung cancer and potential further reductions in mediastinoscopy. It behooves endoscopists to adequately document the medical indications for TBNA in anticipation of the almost certain prepayment and postpayment reviews of these now highly reimbursed and frequently performed procedures. 41,42 We expect the pulmonary community to continue as responsible stewards of our limited health-care resources but in accord with the new guidelines applicable to their patients 40 and not driven by windfall profits to the facilities where they practice. 29,30 Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Manaker has received fees as a grand rounds speaker, lecturer, consultant, and expert witness on documentation, coding, billing, and reimbursement from hospitals, physicians, departments, practice groups, professional societies, insurers, and various attorneys. In March 2011, he received $5,400 from Aetna Inc for consultation on diagnosis coding. He also serves on the Hospital Outpatient Panel, a federal advisory commission to the Centers for Medicare & Medicaid Services. Dr Vachani has received research grants from Allegro Diagnostics Corp and Integrated Diagnostics Inc and advisory board fees from Allegro Diagnostics Corp and Genentech, Inc. Role of sponsors: The Pennsylvania Department of Health specifically disclaims responsibility for any analyses, interpretations, or conclusions. References 1. Centers for Medicare & Medicaid Services. Hospital Outpatient Prospective Payment System. Addendum B. Centers for Medicare & Medicaid Services website. gov/medicare/medicare-fee-for-service-payment/hospital OutpatientPPS/Addendum-A-and-Addendum-B-Updates- Items/2012October-AddendumB.html. Released October Accessed January, 5, Centers for Medicare & Medicaid Services. Calculation of APC payment rates. In: Medicare Claims Processing Manual Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPSS). 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