GI Path or Cyto?

[MetroPath]

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if you had to choose one fellowship which one would you choose and why?

 

[Pathbusiness]

Cyto. Everyone learns GI in practice.

 

[LADoc00]

sigh...we have like 12+ threads on this.

Cyto is near useless now from a business standpoint. Cyto reimbursement has been driven down to near zero profit, ROSE work is worst reimbursing activity that actually pays something and cyto itself is very high medical legal liability.

I had a partner with a cyto boards and he said it was completely useless.

GI is very much in demand by GI docs looking to park very profitable caseloads somewhere. A group of 6 busy GI docs could theoretically produce 600-900K+ in global pathology payments every year.

 

[MetroPath]

sigh...we have like 12+ threads on this.

Cyto is near useless now from a business standpoint. Cyto reimbursement has been driven down to near zero profit, ROSE work is worst reimbursing activity that actually pays something and cyto itself is very high medical legal liability.

I had a partner with a cyto boards and he said it was completely useless.

GI is very much in demand by GI docs looking to park very profitable caseloads somewhere. A group of 6 busy GI docs could theoretically produce 600-900K+ in global pathology payments every year.

As always, Thanks for chiming in LA.

 

[LADoc00]

No problem. As if the job market itself wasnt challenging enough, I refuse to be silent if I actually see misinformation about pathology market forces. GI and GU fellowships give groups a shot to repatriate very lucrative margin workloads back their community practice and away from podlabs and national reference pirates.

 

[cmz]

GI by far. LaDoc00 is 100% correct about the economics. Will this stay true for the next 5-10 years though?

 

[deleted314957]

Depends on your goal. For easy pickin’s for lifelong employment-Forensics.
For academics-anything that flips your skirt.
For P.P.- a quickie Executive M.B.A. ( i am serious as a heart attack). However,
the most important thing is that you GET OUT OF THE NEST you have been in for your entire life ANYWAY YOU CAN and get “real” on-your-own experience. A less than desirable job in Macon, GA for a couple years will do that for example. So will the military.
What lots of young folks don’t realized is that when I hire you, I fully expect you to be
COMPETENT (not expert) at anatomic and clinical pathology. That includes cyto, GI,
heme, BB. If there is the very, very occasional BX (of anything) that we can’t figure out
after thorough w/u and group consultation we will just ship it. Why pay someone big bucks to, MAYBE, backstop me/us a couple times a year?
If your my employee and, hopefully, partner to be, you’d better be WILLING AND ABLE to cover it all. There is no one fellowship that helps you in my hiring scenario for PP.
Clearly, this screed is directed at folks who harbor PP partnership ambitions which seem to be less available than in my day. I suspect they will be quite unusual in the not-too-distant future.

 

[MetroPath]

Depends on your goal. For easy pickin’s for lifelong employment-Forensics.
For academics-anything that flips your skirt.
For P.P.- a quickie Executive M.B.A. ( i am serious as a heart attack). However,
the most important thing is that you GET OUT OF THE NEST you have been in for your entire life ANYWAY YOU CAN and get “real” on-your-own experience. A less than desirable job in Macon, GA for a couple years will do that for example. So will the military.
What lots of young folks don’t realized is that when I hire you, I fully expect you to be
COMPETENT (not expert) at anatomic and clinical pathology. That includes cyto, GI,
heme, BB. If there is the very, very occasional BX (of anything) that we can’t figure out
after thorough w/u and group consultation we will just ship it. Why pay someone big bucks to, MAYBE, backstop me/us a couple times a year?
If your my employee and, hopefully, partner to be, you’d better be WILLING AND ABLE to cover it all. There is no one fellowship that helps you in my hiring scenario for PP.
Clearly, this screed is directed at folks who harbor PP partnership ambitions which seem to be less available than in my day. I suspect they will be quite unusual in the not-too-distant future.

I wonder how many graduating residents feel competent with CP straight out of residency lol. Seems like you pass the boards and learn on the job.

 

[deleted314957]

I wonder how many graduating residents feel competent with CP straight out of residency lol. Seems like you pass the boards and learn on the job.

I did. ( really. no lol ) Spent two years working with MD boarded heme, micro, bb, chem etc on a daily basis. It was expected and required.If folks can’t do that anymore I guess I’m lucky I’m not an employer anymore. What the f do y’all do for two years?

 

[FLY1]

What additional fellowship goes well with GI?

 

[Adrian Cocot]

From someone who's done both:
Cyto is preferable if you want to be a better pathologist.
GI is preferable if you want to be a richer pathologist.

Remember, though: Neither fellowship will make up for a bad personality, ugly looks or an unpleasant telephone voice.

 

[pathslides]

What additional fellowship goes well with GI?

Are you trying to be an academic? Why do you want to waste another year doing another fellowship? You are already wasting a year doing a non boarded fellowship with GI. GI is bread and butter for most generalists, a fellowship is not needed. Don’t waste time and lose another year of proper income.

 

[WEBB PINKERTON]

Cyto has two trends going on that are killing the field. Obviously HPV testing replacing Pap test is a big one. The other is core biopsies becoming the new FNA. Cyto fellowship is a waste nowadays. If you can't look at smears or touch preps and tell you are in a lesion, you must have went to a bad program.

ROSE can ruin your day, especially if you have a pulmonologist sampling 4 or 5 lymph nodes before switching to navigation for the lung nodule, and pays next to nothing. I wonder how much longer pathologists will even provide the service. Something has to give due to the time commitment and lack of reimbursement. Is it even useful? Seems like just throwing some cores into formalin works out just fine and you don't ruin the cores by touching them to a slide.

 

[Unty]

Are you trying to be an academic? Why do you want to waste another year doing another fellowship? You are already wasting a year doing a non boarded fellowship with GI. GI is bread and butter for most generalists, a fellowship is not needed. Don’t waste time and lose another year of proper income.

True but some jobs require GI fellowship trained pathologists for marketing purposes. Some require a surgical Path fellowship training as well.

 

[octopusprime]

Cyto has two trends going on that are killing the field. Obviously HPV testing replacing Pap test is a big one. The other is core biopsies becoming the new FNA. Cyto fellowship is a waste nowadays. If you can't look at smears or touch preps and tell you are in a lesion, you must have went to a bad program.

ROSE can ruin your day, especially if you have a pulmonologist sampling 4 or 5 lymph nodes before switching to navigation for the lung nodule, and pays next to nothing. I wonder how much longer pathologists will even provide the service. Something has to give due to the time commitment and lack of reimbursement. Is it even useful? Seems like just throwing some cores into formalin works out just fine and you don't ruin the cores by touching them to a slide.

Both good points, but I think the reimbursement for those is fairly good... I mean not compared to spending an equivalent time just pumping out 88305s, but it beats taking pictures for conference or windshield time for outreach. A 2 or 3 station survey, with cell blocks, with BAL, with brush, +/- some biopsies, plus IHCs or specials if needed...might be an investment of 45-90 min up front, but the sign-out is fairly easy, particularly since you've already looked at half the material, and not an insignificant amount.
I frankly welcome the breaks from sitting at my desk
Let's say a 2 station sample...
88173 x 2
88172 x 2
88177 x 4 (assuming 3 passes each)
88305 x 2 (cell blocks)
88305 x 1 (biopsy)
88112 x 1 (brush)
88342/1 x X (if needed)
88312 x X (if needed)

 

[WEBB PINKERTON]

Our pulmonologists only get blocks of time on certain days of the week. It is routine for us to spend an entire day down there and work into the night at times.

We don't bill 88177 very often because they will bring 5 passes per station quickly which is one evaluation episode. So we usually just bill 88172. Only if there is no lymphs do they go back to the station and we bill 88177 for subsequent evaluation episode(s).

You can generate a lot of charges by not attending these procedures. Put the stations in a fixative. Cut the brush off and put it in fixative.

The deeper question is "has the importance of ROSE been oversold to us?" I know many who feel it has been. It is a horrible use of our time.

 

[octopusprime]

Our pulmonologists only get blocks of time on certain days of the week. It is routine for us to spend an entire day down there and work into the night at times.

We don't bill 88177 very often because they will bring 5 passes per station quickly which is one evaluation episode. So we usually just bill 88172. Only if there is no lymphs do they go back to the station and we bill 88177 for subsequent evaluation episode(s).

You can generate a lot of charges by not attending these procedures. Put the stations in a fixative. Cut the brush off and put it in fixative.

The deeper question is "has the importance of ROSE been oversold to us?" I know many who feel it has been. It is a horrible use of our time.

If you do 5 passes on a station 7 node, that's 88172 x 1 [initial] and 88177 x 4 [each separate additional evaluation episode, same site].

You go: 88173x1, 88172x1, 88177xX, 88305x1
You don't go: 88173x1, 88305x1 if FNA / 88112x1 for Brush

Probably oversold, but IMO generates decent revenue if you have efficient GI and Pulm docs

 

[Thrombus]

I need GI help with about 0.1-0.3% of my GI cases and need Cyto help with about the same. Not sure why anyone needs a fellowship in either unless you are planning on working in some large consultative practice (Mayo, etc).

Unless the JOB MARKET IS COMPLETELY SATURATED AND THE ONLY WAY TO GET BUSINESS IS TO HAVE SPENT ONE OF THE YEARS OF YOUR LIFE WORKING FOR BIG CORRUPT ACADEMIA CARTEL!

FPN!!

 

[WEBB PINKERTON]

If you do 5 passes on a station 7 node, that's 88172 x 1 [initial] and 88177 x 4 [each separate additional evaluation episode, same site].

You go: 88173x1, 88172x1, 88177xX, 88305x1
You don't go: 88173x1, 88305x1 if FNA / 88112x1 for Brush

Probably oversold, but IMO generates decent revenue if you have efficient GI and Pulm docs

Your billing example for station 7 works IF you are just getting one slide per evaluation episode. Most places don't work that way. They bring out passes while you are staining and screening the previous passes.

An evaluation episode can be one pass or it could be 10 passes. Each separate pass DOES NOT equal an evaluation episode. They bring us 5 passes (alternating two surgical techs carrying needles) which is 1 evaluation episode (88172). They are doing 5 passes regardless of what we say before switching to another station. To bill for 88177, there has to be a need to do another evaluation episode (no lymphs or whatever). Our payers have been a headache and we have to challenge a lot despite excellent documentation.

I used to be a diehard cytopathologist. Now I feel like someone who has seen the light and escaped scientology, I mean cytopathology.

Better hope fee for service doesn't go away on these cases. Imagine bundled payments.

 

[octopusprime]

Your billing example for station 7 works IF you are just getting one slide per evaluation episode. Most places don't work that way. They bring out passes while you are staining and screening the previous passes.

An evaluation episode can be one pass or it could be 10 passes. Each separate pass DOES NOT equal an evaluation episode. They bring us 5 passes (alternating two surgical techs carrying needles) which is 1 evaluation episode (88172). They are doing 5 passes regardless of what we say before switching to another station. To bill for 88177, there has to be a need to do another evaluation episode (no lymphs or whatever). Our payers have been a headache and we have to challenge a lot despite excellent documentation.

I understand your reasoning (NCCI policy manual states an “additional evaluation episode…cannot begin before an assessment is rendered by the pathologist to the operating physician, and the operating physician uses the assessment to determine whether additional needle passes should be performed.”)
But practically speaking, most (like all) thyroid FNAs need >1 pass, so the radiologist can wait 60 seconds for pass 1 to be dried, stained, reviewed, or he can go ahead with pass 2 with the implicit understanding that you're never going to declare adequacy after 1 pass.

If your pulmo guys are doing 5 passes in the time it takes you to read 1 or before you get there, that's unfortunate and frustrating.

 

[Med Director New England]

Billing multiple ROSEs is getting so difficult. First multiple 88172 just got rejected, 88177 was supposed to fix this but we still get this bill denied many times. Then you spend resources going after literally 20 bucks. Our group now gives a new accession number any time the operator changes locations during the same procedure (rather than adding a part to the initial accession) just b/c denials are less likely & you can drop multiple 172s and 173s this way. Sure it won’t be long before payers Bundle everything.

The lack of a reasonable bill for the second pass is why many depts outside of academia are starting to send a Cytotech instead of a pathologist to attend lengthy ROSE procedures. Even in academia you are likely getting a cytopath fellow and not an attending.

Cytotechs are perfectly capable of performing ROSES and it is far better for cytopaths to be signing out and perhaps backing up a cytotech for The occasion difficult ROSEs, ideally close by.

 

[deleted314957]

I’m with Webb and Med Dir. That stuff became impossible from a time/money
perspective in my prior solo capacity. ROSE was a rare event for me by the time
i hung it up in 2013.

 

[octopusprime]

Our group now gives a new accession number any time the operator changes locations during the same procedure (rather than adding a part to the initial accession) just b/c denials are less likely & you can drop multiple 172s and 173s this way.

That's kosher? Multiple accession numbers for a single patient encounter? In what other setting would insurance companies let that fly? That seems far more of a stretch than multiple 88177s, though I suppose I've never faced denial for our 88177s so I haven't been left to search for other options.

The lack of a reasonable bill for the second pass is why many depts outside of academia are starting to send a Cytotech instead of a pathologist to attend lengthy ROSE procedures. ...
Cytotechs are perfectly capable of performing ROSES and it is far better for cytopaths to be signing out and perhaps backing up a cytotech for The occasion difficult ROSEs, ideally close by.

In theory yes, sending a cytotech would be fine, but implicit on that is actually having a good cytotech [they're a dying breed and it's not exactly a booming field], one you trust, and one that the clinicians will be content with.

i spend countless hours going to meetings, traveling, billing, attending tumor boards, directing clin lab, etc, that rapid on-site is just a drop in the bottomless 'not worth my time' / appeasement bucket...a not insignificant part of the job is keeping people happy, being fodder for others' proclivities, and for us historically basement dwellers, the opportunity to display some skills & convey a willingness to eat the mess of 21st century healthcare for breakfast is sometimes all you have when it comes time to re-up your contracts. Even if I wanted to push glass for 8 hours a day straight, there's not enough glass for every partner to push glass all day every day.

 

[WEBB PINKERTON]

I understand your reasoning (NCCI policy manual states an “additional evaluation episode…cannot begin before an assessment is rendered by the pathologist to the operating physician, and the operating physician uses the assessment to determine whether additional needle passes should be performed.”)
But practically speaking, most (like all) thyroid FNAs need >1 pass, so the radiologist can wait 60 seconds for pass 1 to be dried, stained, reviewed, or he can go ahead with pass 2 with the implicit understanding that you're never going to declare adequacy after 1 pass.

If your pulmo guys are doing 5 passes in the time it takes you to read 1 or before you get there, that's unfortunate and frustrating.

To bill for 88177, I guess they expect us to do just that...look at one slide and then tell the physician to do another pass. Waste even more time for the pathetic ROSE reimbursement. We have been "by the book" here but I am sure many are just billing a bunch of 88177s. Our billing lady scares us all the time because she has fear of an audit. How would someone prove those weren't separate evaluation episodes anyways? Just document it like they were.

 

[WEBB PINKERTON]

That's kosher? Multiple accession numbers for a single patient encounter? In what other setting would insurance companies let that fly? That seems far more of a stretch than multiple 88177s, though I suppose I've never faced denial for our 88177s so I haven't been left to search for other options.



In theory yes, sending a cytotech would be fine, but implicit on that is actually having a good cytotech [they're a dying breed and it's not exactly a booming field], one you trust, and one that the clinicians will be content with.

i spend countless hours going to meetings, traveling, billing, attending tumor boards, directing clin lab, etc, that rapid on-site is just a drop in the bottomless 'not worth my time' / appeasement bucket...a not insignificant part of the job is keeping people happy, being fodder for others' proclivities, and for us historically basement dwellers, the opportunity to display some skills & convey a willingness to eat the mess of 21st century healthcare for breakfast is sometimes all you have when it comes time to re-up your contracts. Even if I wanted to push glass for 8 hours a day straight, there's not enough glass for every partner to push glass all day every day.

I guess this is were telepathology could play a role. I have seen the occasional lab that has surgical techs making slides and sending images to pathologists. With pathology quickly becoming centralized and closing AP labs at an alarming rate, it will be impossible to provide a pathologist on-site for ROSE at many hospitals without some sort of telepathology. Or will a pathology midlevel like pathology assistant be positioned in these satellite hospitals to handle things?

CAP did a survey about ROSE not that many years ago. Around 50 percent of the respondents said they are providing the service.

 

[WEBB PINKERTON]

Billing multiple ROSEs is getting so difficult. First multiple 88172 just got rejected, 88177 was supposed to fix this but we still get this bill denied many times. Then you spend resources going after literally 20 bucks. Our group now gives a new accession number any time the operator changes locations during the same procedure (rather than adding a part to the initial accession) just b/c denials are less likely & you can drop multiple 172s and 173s this way. Sure it won’t be long before payers Bundle everything.

The lack of a reasonable bill for the second pass is why many depts outside of academia are starting to send a Cytotech instead of a pathologist to attend lengthy ROSE procedures. Even in academia you are likely getting a cytopath fellow and not an attending.

Cytotechs are perfectly capable of performing ROSES and it is far better for cytopaths to be signing out and perhaps backing up a cytotech for The occasion difficult ROSEs, ideally close by.

God, if we created separate accession numbers for each station our FNA accession count would look really high.

I agree, bundled payments are coming. The typical bronch is a ton of duplicate work. FNA, forceps, washings, brushings..it is insane.

Another thing we do is access forcep biopsies during bronchs sometimes so we get to bill out some 88333 and 88334s.

I read some people are billing for accessing the bronch brushings as well. They are billing 88333 and 88334s for looking at those during the procedure.

 

[cmz]

We bill out 88172 for ROSE and 88177. We are careful to document the site, pass # and episode # for each interpretation. For example, if you're given three slides all at once for station 7 LN you can only technically bill 88177 x 1 since that is all "one episode." I think I read somewhere that medicare will not reimburse 88177 after you've called one of the slides "adequate". I've never bothered to check this rule but just because something is adequate doesn't mean the rest of the work I do for ROSE shouldn't be reimbursed.

All in all, I hate ROSE with a passion. I am trying to make it outlawed at all of our hospitals.

 

[WEBB PINKERTON]

I don't see how we have much control on whether to outlaw it or not. A good interventional pulmonologist brings in a lot of money for the hospital. If they want path, then you have to find a way to keep them happy. Our IP guys do a lot of procedures in OR and even hybrid OR as well.

I laughed this morning checking my email. I got a timely link to this page from the ASC

Rapid On-Site Evaluation (ROSE) of Fine Needle Aspiration Cytology | ASC Education

Not sure why they are calling it Advanced Cytopathology Education. Not exactly rocket science.

Someday we will look back at ROSE and say "remember when we wasted hours a day screening for lymphocytes for like 20 dollars an hour?"

 

[y2k_free_radical]

That's kosher? Multiple accession numbers for a single patient encounter? In what other setting would insurance companies let that fly? That seems far more of a stretch than multiple 88177s, though I suppose I've never faced denial for our 88177s so I haven't been left to search for other options.



In theory yes, sending a cytotech would be fine, but implicit on that is actually having a good cytotech [they're a dying breed and it's not exactly a booming field], one you trust, and one that the clinicians will be content with.

i spend countless hours going to meetings, traveling, billing, attending tumor boards, directing clin lab, etc, that rapid on-site is just a drop in the bottomless 'not worth my time' / appeasement bucket...a not insignificant part of the job is keeping people happy, being fodder for others' proclivities, and for us historically basement dwellers, the opportunity to display some skills & convey a willingness to eat the mess of 21st century healthcare for breakfast is sometimes all you have when it comes time to re-up your contracts. Even if I wanted to push glass for 8 hours a day straight, there's not enough glass for every partner to push glass all day every day.

I just returned from a ROSE where i diagnosed papillary carcinoma on a thyroid.We would have some leverage to ask for reimbursement of our time if we weren't a dime a dozen so to speak.Being the MEDICAL DIRECTOR of the laboratory may pay me less per hour than a ROSE,but i must do it to keep surgical pathology.

 

[Thrombus]

The plumber gets more money to unclog the toilet than we get paid for Rapid Assessments.

FPN!!

 

[WEBB PINKERTON]

The plumber gets more money to unclog the toilet than we get paid for Rapid Assessments.

FPN!!

Yea, but can the plumber take whatever is clogging the toilet back to his workplace and submit cell blocks, order special stains, do cultures etc?

 

[Med Director New England]

We bill out 88172 for ROSE and 88177. We are careful to document the site, pass # and episode # for each interpretation. For example, if you're given three slides all at once for station 7 LN you can only technically bill 88177 x 1 since that is all "one episode." I think I read somewhere that medicare will not reimburse 88177 after you've called one of the slides "adequate". I've never bothered to check this rule but just because something is adequate doesn't mean the rest of the work I do for ROSE shouldn't be reimbursed.

All in all, I hate ROSE with a passion. I am trying to make it outlawed at all of our hospitals.

This is true about deeming adequate - no additional 177s after that for that particular target. We get around this by avoiding saying adequate and writing "need additional passes for ancillary studies" or similar if the pass is diagnostic but the person performing the onsite ROSE feels more is needed for the molecular work-up (as in the case of lung cancers)... The person performing the ROSE would tell the operator we have enough for a diagnosis but need more to enrich the cellblock for all the studies oncology will need to treat.

But again if you practice at a place diagnosing and treating lung cancers hopefully you are big enough dept to have some cytotechs who can be trained up to support ROSEs. If your docs performing the procedures object to CTs performing ROSEs educate them too - a well trained cytotech is sufficient. If you have doubts keep a close eye on it until you are comfortable sending a cytotech out to perform an indep. ROSE. Within a medical group or system of employed docs - Hospital admins will side with path in this argument much more cost effective to pay CTs to support ROSEs.

I have good relationships with the GI docs, interventional radiologists and pulmonary who perform FNAs and for the most part they buy into the notion that CTs are capable of performing independent ROSEs. On occasional one will absolutely insist on a cytopath being present b/c they feel a particular case might be more difficult, the patient is a VIP or similar -- in these cases I oblige to maintain good relations

 

[cmz]

This is true about deeming adequate - no additional 177s after that for that particular target. We get around this by avoiding saying adequate and writing "need additional passes for ancillary studies" or similar if the pass is diagnostic but the person performing the onsite ROSE feels more is needed for the molecular work-up (as in the case of lung cancers)... The person performing the ROSE would tell the operator we have enough for a diagnosis but need more to enrich the cellblock for all the studies oncology will need to treat.

But again if you practice at a place diagnosing and treating lung cancers hopefully you are big enough dept to have some cytotechs who can be trained up to support ROSEs. If your docs performing the procedures object to CTs performing ROSEs educate them too - a well trained cytotech is sufficient. If you have doubts keep a close on eye it until you are comfortable sending a cytotech out to perform an indep. ROSE. Within a medical group or system of employed docs - Hospital admins will side on path in this argument much more cost effective to pay CTs to support ROSEs.

I have good relationships with the GI docs, interventional radiologists and pulmonary who perform FNAs and for the most part they buy into the notion that CTs are capable of performing independent ROSEs. On occasional one will absolutely insist on a cytopath being present b/c they feel a particular case might be more difficult, the patient is a VIP or similar -- in these cases I oblige to maintain good relations

Thank you for the tip! I will start phrasing my reports slightly different...

I am at a place where they continue to do super dimensional navigational bronchs and while we get a diagnosis of malignancy we often fail to get enough tissue despite telling the operator/pulmonary doc that we need more. This is a notoriously difficult system to use and one slip and you're outside of the target lesion. My partner has been in on these procedures for up to 3 hours. It's madness. We are at the point now where we're actively trying to get the machine shipped to another state where someone else could use it within the health system I work in.

 

[WEBB PINKERTON]

This is true about deeming adequate - no additional 177s after that for that particular target. We get around this by avoiding saying adequate and writing "need additional passes for ancillary studies" or similar if the pass is diagnostic but the person performing the onsite ROSE feels more is needed for the molecular work-up (as in the case of lung cancers)... The person performing the ROSE would tell the operator we have enough for a diagnosis but need more to enrich the cellblock for all the studies oncology will need to treat.

But again if you practice at a place diagnosing and treating lung cancers hopefully you are big enough dept to have some cytotechs who can be trained up to support ROSEs. If your docs performing the procedures object to CTs performing ROSEs educate them too - a well trained cytotech is sufficient. If you have doubts keep a close eye on it until you are comfortable sending a cytotech out to perform an indep. ROSE. Within a medical group or system of employed docs - Hospital admins will side with path in this argument much more cost effective to pay CTs to support ROSEs.

I have good relationships with the GI docs, interventional radiologists and pulmonary who perform FNAs and for the most part they buy into the notion that CTs are capable of performing independent ROSEs. On occasional one will absolutely insist on a cytopath being present b/c they feel a particular case might be more difficult, the patient is a VIP or similar -- in these cases I oblige to maintain good relations

If you send a non-physician, then you can't bill for 88172 or 88177. A physician must be screening the slides. A cytotech may be able to screen the slides but you are leaving that big money on the table. LOL. The lab may really need those TC payments due to the loss of all the pap tests. I don't know many labs that can afford to hire a cytotech nowadays. There just isn't enough to bill for (outside large med centers) and no path groups want to employ them.

I had a two hour bronch tonight.. Got home at 7pm!

 

[WEBB PINKERTON]

Thank you for the tip! I will start phrasing my reports slightly different...

I am at a place where they continue to do super dimensional navigational bronchs and while we get a diagnosis of malignancy we often fail to get enough tissue despite telling the operator/pulmonary doc that we need more. This is a notoriously difficult system to use and one slip and you're outside of the target lesion. My partner has been in on these procedures for up to 3 hours. It's madness. We are at the point now where we're actively trying to get the machine shipped to another state where someone else could use it within the health system I work in.

We put a **** ton of passes into two conical tubes..one tube with formalin and one with cytolyt. We usually get enough material for cell blocks and are able to do all necessary ancillary testing. Although if Guardant 360 testing takes off, it may not be necessary. Blood work will give the oncologists all the info they need.

 

[jupiterianvibe]

If you send a non-pathologist, then you can't bill for 88172 or 88177. A pathologist must be present and screening the slides. A cytotech may be able to screen the slides but you are leaving that big money on the table. LOL. The lab may really need those TC payments due to the loss of all the pap tests. I don't know many labs that can afford to hire a cytotech nowadays. There just isn't enough to bill for (outside large med centers) and no path groups want to employ them.

I had a two hour bronch tonight.. Got home at 7pm!

This seems so inefficient. Not a dig at you, but at the demand for these time consuming and somewhat poorly reimbursed procedures.

This is one instance where a digital system would be valuable. You'd not have to even leave your office. Would that still be legally billable or does a pathologist have to be on site?
Is it possible to structure your volume around signing out other surgicals while waiting for ROSE specimens to come for assessment or is there enough downtime for that?

I'm asking these questions because I do not perform ROSE.

 

[WEBB PINKERTON]

I don't know much about digital systems to be honest.

Yes, you can bill when someone sends you images.

There was a day a month ago with over 6 hours worth of time spent doing ROSE on station after station. Ended up leaving the last case around 9pm.

Remember when pathologists were bitching about ENTs and other physicians doing ROSE? Bet we won't complain again about that. Let em. LOL

 

[Med Director New England]

If you send a non-physician, then you can't bill for 88172 or 88177. A physician must be screening the slides. A cytotech may be able to screen the slides but you are leaving that big money on the table. LOL. The lab may really need those TC payments due to the loss of all the pap tests. I don't know many labs that can afford to hire a cytotech nowadays. There just isn't enough to bill for (outside large med centers) and no path groups want to employ them.

I had a two hour bronch tonight.. Got home at 7pm!

Exactly
So you and your group need to make a value based decision. Is two hours of your time worth the ~ 80 dollars in pro revenue or do you want to sign out 15-20 biopsy cases instead and pay a CT about 80 dollars to cover the ROSEs and eat the lost pro (160 dollar cost to bill nearly 10x as much). Proximity is very key here -- My group is close enough to the procedures to pop in for part of it, sign off on at least some of the ROSE reads and capture some of the billing. But I personally would never spend 2-3 hrs straight in one procedure. If you are doing your routine sign out far away from the procedure this is likely not possible and probably not worth your time.

If you are employed and get push back from your hosp administrators invite your CMO or CEO to shadow you on one lung procedure and afterwards show him/her the pro bill generated.
If your proceduralists object and make a case for patient impact due to more ND outcomes, get everyone together (path, FNA-ologists, hosp admins) and hash it out. Providing 100% MD coverage for ROSEs is very expensive and someone has to pay for it. CT coverage is a reasonable alternative, esp if the cytopaths are sitting close enough to help out on the 1 in 30 truly hard ROSE. In my area CTs are not hard to find, that may not be the case everywhere but as you have mentioned before the impact of HPV testing should lower the number of women Pap'ed - that will substantially reduce a lot of CT hours and free up CT time for non-gyn stuff like ROSEs.

 

[y2k_free_radical]

Exactly
So you and your group need to make a value based decision. Is two hours of your time worth the ~ 80 dollars in pro revenue or do you want to sign out 15-20 biopsy cases instead and pay a CT about 80 dollars to cover the ROSEs and eat the lost pro (160 dollar cost to bill nearly 10x as much). Proximity is very key here -- My group is close enough to the procedures to pop in for part of it, sign off on at least some of the ROSE reads and capture some of the billing. But I personally would never spend 2-3 hrs straight in one procedure. If you are doing your routine sign out far away from the procedure this is likely not possible and probably not worth your time.

If you are employed and get push back from your hosp administrators invite your CMO or CEO to shadow you on one lung procedure and afterwards show him/her the pro bill generated.
If your proceduralists object and make a case for patient impact due to more ND outcomes, get everyone together (path, FNA-ologists, hosp admins) and hash it out. Providing 100% MD coverage for ROSEs is very expensive and someone has to pay for it. CT coverage is a reasonable alternative, esp if the cytopaths are sitting close enough to help out on the 1 in 30 truly hard ROSE. In my area CTs are not hard to find, that may not be the case everywhere but as you have mentioned before the impact of HPV testing should lower the number of women Pap'ed - that will substantially reduce a lot of CT hours and free up CT time for non-gyn stuff like ROSEs.

Our radiology department is getting overwhelmed by CT's from ER-this wouldn't pass at our hospital imo

 

[WEBB PINKERTON]

Exactly
So you and your group need to make a value based decision. Is two hours of your time worth the ~ 80 dollars in pro revenue or do you want to sign out 15-20 biopsy cases instead and pay a CT about 80 dollars to cover the ROSEs and eat the lost pro (160 dollar cost to bill nearly 10x as much). Proximity is very key here -- My group is close enough to the procedures to pop in for part of it, sign off on at least some of the ROSE reads and capture some of the billing. But I personally would never spend 2-3 hrs straight in one procedure. If you are doing your routine sign out far away from the procedure this is likely not possible and probably not worth your time.

If you are employed and get push back from your hosp administrators invite your CMO or CEO to shadow you on one lung procedure and afterwards show him/her the pro bill generated.
If your proceduralists object and make a case for patient impact due to more ND outcomes, get everyone together (path, FNA-ologists, hosp admins) and hash it out. Providing 100% MD coverage for ROSEs is very expensive and someone has to pay for it. CT coverage is a reasonable alternative, esp if the cytopaths are sitting close enough to help out on the 1 in 30 truly hard ROSE. In my area CTs are not hard to find, that may not be the case everywhere but as you have mentioned before the impact of HPV testing should lower the number of women Pap'ed - that will substantially reduce a lot of CT hours and free up CT time for non-gyn stuff like ROSEs.

Different pots of money for us and technical staff. We have little say in staffing. I would think it would be hard to find someone to come work part time on the Indiana, Kentucky border.

 

[Med Director New England]

Different pots of money for us and technical staff. We have little say in staffing. I would think it would be hard to find someone to come work part time on the Indiana, Kentucky border.

fair enough, these things are never easy...

One other thing - you guys are providing a valuable service in helping to diagnose and sub-type lung CA. If your hospital has an affiliated or integrated cancer center and treats these patients surgically and oncologically - there are tons of money there in the form of facility fees, etc. You guys are in essense helping to put fannies in the beds, procedure rooms and ultimately the cancer center (assuming you keep these pts).

you and you're colleagues are also helping your pulmonary colleagues practice crush it too. They are probably there so late and keeping you there so late b/c I bet they are taking same day referrals. Someone sees a PCP at 11 am, told they have a lung lesion picked up on imaging and they call refer them later that day to pulmonary for biopsy and sometimes the nervous family and patient gets an answer same day. Patient's, PCPs love this and this level of service strengthens the PCP-pulmonary referral bond. Hospital wins too, 2nd shift RNs and staff are clicking out procedures until dinner time....hopefully your pulmonary group appreciates this

You guys do a crappy job, the FNA'ologist struggle, patient satisfaction goes down, some of them leak to other cancer centers after diagnosis. It is good for bean counters to understand this when you ask for resources.

 

[Torsed]

I did cyto and although I enjoy it, I would tell you to go GI.