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H&N surgery

Discussion in 'Otolaryngology' started by Ibn Alnafis MD, Apr 28, 2012.

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  1. Ibn Alnafis MD

    Ibn Alnafis MD

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    I have lately been reading more often in the ENT section of this forum, and I'm falling in love with this specialty. My aggressive and doer-rather-than-thinker type of personality cause to be always attracted toward procedural-based specialty, especially those involving surgery.

    If you, docs, don't mind, please answer the following questions:

    I was wondering how operative is H&N surgery in comparison to ortho? Is it geared more toward 3:2 surgical/clinical practice model?

    Do head and neck surgeons perform other "bread & butter" procedures?

    Are surgeons practicing in pp deprived from encountering cool, long, complex cases?

    How much medicine does the specialty involve?

    Thank you,
  2. VisionaryTics

    VisionaryTics SeƱor Member

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    Are you talking about ENT or "head and neck surgery"? Head and neck is a sub-specialty within ENT focusing on treatment of head and neck cancer.
  3. Ibn Alnafis MD

    Ibn Alnafis MD

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    Sorry for the confusion. I meant Head and Neck surgery.
  4. OtoHNS

    OtoHNS ENT Attending

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    1. I don't know that much about ortho, but I'd guess H&N is less operative than ortho. The true surgical cases that you do get in H&N though are going to frequently be big ones though. You'll also do a lot of staging endoscopies and trachs, even in patients who eventually are treated with chemo/radiation. In all subspecialties of ENT, you will spend more days in clinic than in the OR. At my residency, the H&N attendings usually operated 1, sometimes 2 days a week (though those days were 2 rooms running at a time).

    2. If they want to. In my experience, H&N guys don't do many tubes/tonsils/pedi cases. My H&N attendings did a fair amount of sinus surgery, laryngeal procedures, and sleep apnea procedures.

    3. No, but they are much rarer than in an academic center where every H&N case from 100 miles in every direction is funneled. Most PP ENTs refer those cases because 1. it does not make economic sense to do them and 2. the patients are probably better served in a busy tertiary H&N center.

    4. Do you mean internal medicine or medical management of ENT/H&N issues? For most inpatient medical issues, an intern-level of knowledge is adequate. I would consult a hospitalist or other medical specialist for most non-routine issues.
  5. Ibn Alnafis MD

    Ibn Alnafis MD

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    Thank you for your informative response. I hope you wouldn't mind answering a couple more :oops:

    What are the office days like? Do H&N surgeons perform any office-based procedures, or do they only see new and follow-up patients?

    Do H&N surgeons perform hospital roundings? if so, how often?

    Thank you,
  6. OtoHNS

    OtoHNS ENT Attending

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    1. Usually busy clinic days. Common clinic procedures are fiberoptic laryngoscopies, biopsies of tumors accessible through the mouth, dealing with minor trach-related issues (granulation tissue, etc).

    2. Yes if they have inpatients. The resident team will round on all the service's inpatients daily, and different attendings have different routines as to how often they round on their own patients in person.
  7. otopico

    otopico Attending

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    HNS is probably the most operative of the subspecialties. I am a head and neck surgeon at a tertiary care center where we have four others doing HNS and reconstruction. We typically are in the OR 2-3 days on average, 2 days of clinic and an academic day.

    Because we have general otos, rhinologists and peds oto we don't tend to do bread and butter cases such as tonsils, sinus surgery, tubes except for the occasional patient on call. My usual cases are parotidectomies, thyroidectomies, cancer resections, neck dissections, flap reconstructions of all sorts, tracheotomies, panendoscopies with biopsies.

    I think private practice ENT's do not do a lot of head and neck surgeon, as the above post mentions, because primarily it does not make financial sense. Most cases, particularly the long ones, are labor intensive and require a lot of time not only in the OR but in post operative care. I also agree that they are better off going to a tertiary care center for their cancer care, but I am a bit biased in that regard.

    As far as the amount of medicine, I think most places are moving toward really farming out anything that is not speciality related to the appropriate consults. I still have a bit of medical knowledge from medical school but I would certainly not handle a hypertensive crisis alone but rely on the internal medicine service. As a specialty, there is quite a bit of medical management of patients (ENT specific) including allergy, etc...

    Hope that helps.
  8. Ibn Alnafis MD

    Ibn Alnafis MD

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    OtoHNS and otopico, I appreciate you generous responses. Your informative posts reflect your wise, yet humble personalities. Thank you again.
  9. Fah-Q

    Fah-Q Senior Member

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    I am in private practice and I do a good amount of head and neck cancer. I am fellowship trained and I do my own flaps. It is certainly more work than a tubes and tonsil practice but the patients are great and I enjoy challenging cases. I make plenty of money. Much more than my partners who do general ENT. Head and neck cancer patients are not necessarily better off at a tertiary referral center. The multidisciplinary team I work with are full of outstanding cancer professionals. Many of us used to be faculty at academic programs. We are not lesser doctors because we chose to move on to private practice. We did not suddenly lose our knowledge and experience. I happen to think that I provide outstanding care to my patients but I understand that I'm just a community idiot to those in the ivory towers.
    Last edited: May 1, 2012
  10. otopico

    otopico Attending

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    My comment was certainly not intended as a dig as I have several colleagues in private practice who do head and neck. I certainly applaud your dedication and amount of work you must put into these cancer patients. My comment was more directed at the general oto that dabbles in head and neck without the appropriate resources at his/her disposal including a multidisciplinary team. I'm sure both in your experience as an academic oto as well as in private practice you have been the recipient of such patients that had a glossectomy, no frozen section margins sent, multiple positive margins, etc...

    On a side note, it would be great to hear how you set up your practice to accommodate head and neck and make it profitable.
  11. resxn

    resxn

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    I'm that guy. Well, hopefully not the guy who has the positive margins or does a radical neck when a selective is more appropriate. Rather, I'm the guy who does the general practice except for H&N. I gave that up because I didn't have the mutlidisciplinary tumor board in place and I live in soccer mom world where there is a much better living to be made doing oto, rhino, and laryngo work than there is in cancer in my neck of the woods (pun). I'll do a neck for my thyroid cancer practice which is extensive, but the SCCa and bad salivary gland malignancies go to the practices who have multidisciplinary teams--both ivory tower and private guys, btw.

    I'm not a lesser doc either simply because I don't do H&N. Nor do I consider a H&N guy in the community a lesser doc as long as he's built the right team to work with him and there are plenty of those practices around my area too. I'm also fortunate to have a very strong academic program in town to which I can send the nightmares. I'm glad I've got a group of great private and academics to which I can refer. Both I and my patients are better off for it.
  12. OtoHNS

    OtoHNS ENT Attending

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    I'm in the same boat as Resxn. I prefer to focus on general ENT, sinus, and allergy in my practice. And there's plenty of need for that.

    You can do H+N in private practice, as Fah-Q is doing, but it's going to be a lot more labor-intensive than any other aspect of ENT. For me, it's not worth my time and it's not the best thing for the patient since I do not have access to a multidisciplinary team. I haven't been out of residency for long, and I still feel pretty sharp in my H+N treatment skills after the huge amount I did in residency. After another 10, 15, 20+ years in practice, will I be able to say the same? Probably not.

    I'd also be interested to hear more about Fah-Q's practice- do you have PAs/NPs to help with rounding and inpatient care?
  13. DrBodacious

    DrBodacious H-D Sportster 883C

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    In addition to longer case times, inpatient rounding, need for multidisciplinary teams and other factors mentioned above: a major detriment to me doing H&N in private practice is consistently dealing with patients that are a) dying, or b) afraid of dying.

    These patients require a disproportionate expenditure of resources as far as counseling. I don't mind it while I'm in residency - but to be realistic - in private practice, I'm going to want to give patients more than I can afford in a 15-20 min patient slot.

    The patients will be better served in a H&N focused clinic from the councelling/support side of things too. Nurses and support staff who are consistently dealing with H&N cancer patients will do a better job taking care of their unique needs.
  14. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    I no longer do H&N, obviously.

    That's not where my fellowship directed me. However, I have no formulated opinions about private practice otolaryngologists other than they probably work harder than I do. (They probably make more money too, but not much based on my last year's intake. Nevertheless, I do live a somewhat sheltered life in the University.)

    I know otologists in the community who are very good at what they do, and some of them do more lateral skull base than academic physicians. Some more than I. Some, on the other hand, are not quite so good at what they do. Others are capable, yet don't have the resources. Still others are incapable and thankfully don't have the resources either. I could say things about academic ones as well...

    The problem is always the otolaryngologist who thinks s/he can perform surgery well and consistently doesn't. Those are the problem surgeons who send in the disaster patients to us. I think they are the source of that bias and feeling of superiority in academia -- that and the general likelihood that in academia, we do more complex cases more frequently than in the community.

    But the problem is the ENT who thinks he can but can't...or can, but shouldn't.

    To the OP, I know a lot of H&N'ers who operate 3-4 days per week and have monster clinics 1-2 days per week. I don't know how they do it. In this subspecialty, it's definitely eat what you kill...

    EDIT: ah, post 666. I think I should stop here.
  15. Fah-Q

    Fah-Q Senior Member

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    Since a few of you guys asked, I'll briefly give my thoughts on H&N in private practice. I don't only do H&N but it is probably 60% of my practice.

    There really is no secret to financial viability. I do the case, bill the codes, and get paid....sometimes....3 months later. I think we all have the mental picture of our head and neck patients from residency. They come from far away, uninsured or Medicaid, have no teeth, etc. It is far different in private practice. True, you cannot have a financially viable private H&N practice when you are doing mostly charity and Medicaid cases but there really isn't any ENT practice that can survive with that payor mix. Those patients get sent to the ivory tower where the residents and employed surgeons can have at them.

    Resection and reconstruction CPT's are the most highly reimbursed in ENT. You can spend 8 hours doing tubes and tonsils or you can spend 8 hours doing a hemiglossectomy, neck dissection, and forearm free flap. Either way you are going to make money that day, it just depends on what you enjoy doing more. The H&N case will pay about $6250 for Medicare and perhaps $8000 - $9000 if private insurance. I'm not really sure what a day of tubes and tonsils pays but probably less. The tonsil patients and their parents will call you 6-10 times over the next week, which sucks. The nurse for your inpatient will call you 6-10 times over the next week, which also sucks. I round on all my own patients but this takes me about 30 minutes per day which I usually do over my lunch hour. Cancer patients bring you brownies and tell you things like "you saved my life." Tonsil patients tell you their throat hurts and they are out of pain meds. It's just a personal preference.

    You can make more money doing H&N compared to general ENT. However, the sinus and facial plastics guys will do even better than the head and neck surgeons. Do H&N because you really love it, not for the money. I'm just here to try and dispel the myth that you can't have a profitable H&N private practice. I have no idea where it came from.
  16. resxn

    resxn

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    It is possible, but as I've posted on another thread, there's math to show that that's not necessarily the rule. (This math is a couple years old, but I'm too tired to see what the new allowable is).

    Let's say I do a 41155 (Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection), but not the free flap--I'll leave that for the plastics guy. Let's say the patient already got trached for the sake of argument.

    The RVU for that procedure is 73.52 and the medicare allowable is $2600.20 (nice of them to tack on the 20 cents)

    Now let's look at 69346 (bilateral tubes). The RVU is 4.27, the medicare allowable is $153.49.

    So for the math, let's say the H&N case takes me 6 hours. How many tubes can I get done in 6 hours? Well, I can do 4 an hour fairly easily if I'm running two rooms. So I can theoretically get 24 done. That's a bit of overkill. But for the sake of argument let's look at the numbers--that's $3683.76. Ok, so if we use a more realistic number and say I get 18 cases in that timeframe--that's assuming 3/hr probably fairly low estimate, I still make $2762.82.

    Now, some people would say why the heck would I want to do 18 tubes instead of a cool case like the composite resection. Good question. Many wouldn't. I know I have no interest in doing 18 tubes in a day. But let's say I do 4 sets of tubes, 2 tonsils on kids under 12, and a medium level 4 sinus FESS. That would add up as follows 4x153.49 + 2x268.51 + 1245.43 = $2396.41.

    Well, I'm down $300, but I'm out by noon instead of 3 or 4PM so I have a lucrative afternoon clinic I can still do and make that up and more by 3 or 4PM. I won't have to round on the H&N patient for $0 for the next 7-10 days. I won't have as significant a risk of multiple complications. I won't need to see that patient every month for the next year. And keep in mind that every visit in the first 90 days is free. Well, free isn't a big deal you say because I got a lot for the surgery.

    Then think about this. Every minute you spend seeing that patient without making money, you're losing money. Your staff still makes a salary, you still have rent or a mortgage, you have equipment costs, EMR costs, taxes, insurance, IT costs, etc. In addition, every minute you see that guy, you're not seeing someone who will make money. So it's not a net zero for that 15 mins checking up on him at his 1 month appt. It's zero, minus your overhead, minus the money you would have made seeing someone who would have paid.

    I guarantee I make more money in a non H&N practice in my neighborhood than my good H&N colleagues who do. When we've compared notes, it works out to be about 10% more for those who do over 50% H&N. That's not much overall, but on average they work about 10-15% more hours than I do. Nevertheless, they have far more interesting cases. Although, the occasional crazy FESS is still way better than a H&N case in my opinion.
  17. OtoHNS

    OtoHNS ENT Attending

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    Wow, that's quite a difference. Does the forearm really pay that much?


    Definitely agree that it's a personal preference.

    As far as tonsils (and my other common surgeries), I can generally limit the calls by giving detailed post-op instruction sheets and preparing them for the worst (so that most patients are pleasantly surprised). I also have my nurses call all my surgical patients on POD 1 to see how they are doing. This also pre-empts a lot of calls and makes the patients feel warm and fuzzy.

    When patients do call, 90% of the time it can be handled with some hand-holding and reassurance over the phone by my nurses.

    Those postop calls from inpatient nurses on your big whacks seem like they would be more labor intensive, but again, my view of H+N patients is clouded by my resident experience where the average patient was a malnourished alcoholic with a bunch of undiagnosed comorbidities (exaggeration, kind of...).

    But hell, if you love H+N, more power to you. It's cool that you can still be successful and profitable while doing what you love. Much respect.
  18. resxn

    resxn

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    Now that it's lunch time, I'm not so tired--this is from ent.codingtoday.com for a 41155 (Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck dissection (Commando type))
    Facility Total RVU 89.27
    Allowable $3038.54

    Let's do a coding lesson for fun. Using Fah-Q's surgery and assuming a MRND rather than a selective neck, here's the Medicare numbers:

    CPT 41130 Glossectomy; hemiglossectomy
    Facility Total RVU 39.28
    Allowable $1337.00

    CPT 38724 Cervical lymphadenectomy (modified radical neck dissection)
    Facility Total RVU 43.22
    Allowable $1471.11

    CPT 15757 Radial Forearm Free Flap (includes closure of donation site)
    Facility Total RVU 69
    Allowable $2348.59

    When coding for all insurances including Medicare, you bill in highest order of cost. Medicare will pay only 50% on each subsequent CPT code. So the math is as follows:
    $2348.59 + $1471.11(50%) + $1337.00(50%) = $3752.64

    Overall, you can see that the reimbursement is for the suck. If you end up doing the extirpation yourself and someone else does the flap, then the reimbursement for MRND will be fully reimbursed.

    So there you go. Math is math. An efficient surgeon who has low overhead can make a good living with H&N. Especially if they are doing other general stuff on the side.
    And remember, this math if for Medicare, private payers will often be 25% or more for these cases.
    Last edited: May 8, 2012
  19. Fah-Q

    Fah-Q Senior Member

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    I don't want to get caught up in the details too much on coding. Resxn's post in regards to those CPT's is accurate. But there are 8-10 additional CPT's I would typically bill for the case I described. This is where the difference between his number and my number comes from. Coding big cases correctly makes a huge difference. Everyone entering practice needs to be very knowledgeable with the CPT book and especially the CCI guidelines. This is something I learned in fellowship, not residency.

    Resxn's comment about efficiency is also a very important variable. In his earlier example of a tongue/jaw resection with a neck dissection, that case should really only take about 3-4 hours if you are not doing the flap. If it routinely takes a surgeon 6 hours for that case then they could certainly make more doing several general cases in the same time slot. If you are doing the flap then it will take about 10 hours but there are plenty of reconstruction codes you can bill to make those 10 hours worth your time. Like I said above, it depends on how you prefer to spend your time and what you prefer doing. If you are busy and have a good payor mix then most ENT's will make plenty of money. If you are slow then you just won't make as much but a H&N practice would still be financially viable, in my opinion.
  20. Ibn Alnafis MD

    Ibn Alnafis MD

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    Wow. You guys are the coolest docs ever, which prompts me to ask another question.

    How frequently does an HN surgeon do such complex cases? are they once-in-a-blue-moon type cases, or do they occur on weekly bases?

    I know I'm still in my infantile stages of the medical career ladder, but I like to have a clear vision of what I want to do in the future. The idea of spending 8-10 hours on a complex surgery is a total thrill for me. Perhaps, it's because I haven't experienced it.

    thanks
  21. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    +1 on this comment.

    I have found that understanding the codes and the actual descriptions of the codes has resulted in my knowing more than the coder does about what appropriate codes should apply to the surgeries I perform.

    Interesting that you all follow the transitioned RVUs. Where I am, the wRVUs are what count for us facility folk.
  22. ZagDoc

    ZagDoc Ears, Noses, and Throats

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    Great stuff in this thread, much thanks to the attendings that contribute on here.
  23. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    Thanks, but this will be my last post for his week since I have exceeded my work hours...:p
  24. OtoHNS

    OtoHNS ENT Attending

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    For the other attendings, what are some good resources for learning more about coding/RVUs/etc? I have some basic knowledge but clearly the rest of you could school me in coding like Lebron James playing 1 on 1 against a 12 year old girl.
  25. resxn

    resxn

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    KarenZupko conferences (http://www.karenzupko.com/) is a good but slightly expensive way to start. Really really good. Also, you can have some certified coders come in and do consulting work. If you're not a good coder, you'll be amazed by how much money you can leave on the table with poor coding of surgeries and clinic visits and the consultants may seem like a lot, but often they'll pay for themselves.

    Finally, there are a number of cheap coding resources through Association of Otolaryngology Adminstrators, the Academy, and online coding forums.

    If there was anything that a private practice ENT needs to know cold it's coding. Before you know anything else business wise, know how to get paid for what you do.
  26. OtoHNS

    OtoHNS ENT Attending

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    Thanks for the info!
  27. medstylee

    medstylee 1K Member

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    thank you guys. this is pretty illuminating and helpful, particularly for us mid-level residents who are starting to think about fellowship (for me, H&N in particular).
  28. Ibn Alnafis MD

    Ibn Alnafis MD

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    I'm planning to attend DO school, and was wondering what are the chances of doing a H&N fellowship following AOA ENT residency. On the website of American Head & Neck Society, I read the following:

    "Doctors who have received a D.O. are not eligible to participate in the AHNS match. However, applicants with a D.O. can contact the fellowship programs after the match occurs to see if a position is available and if their qualifications are a fit for the program"

    I was wondering if non-accredited programs would adhere to this policy as well.

    Thank you,
  29. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    Someone may feel free to correct me, but there are no accredited H&N fellowships. I believe the only one that is accredited is the neurotology fellowship. (And not all of those are accredited by the ACGME.)

    A match program doesn't imply anything about the individual programs necessarily.

    Sent from my Nexus S 4G using Tapatalk 2
  30. otopico

    otopico Attending

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    That's correct. There are no ACGME accredited programs in head and neck surgery. The surrogate is essentially the advanced training council through the american head and neck society. Most fellowships go through the AHNS match and they do not allow DO's to apply for the match. They must contact the programs directly and can interview for spots that way. They then have to wait and see if that program matches or not and then hope for the best. Non-AHNS fellowships I think are less likely to have these types of stipulations, however I would contact them directly to find out.

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