Mitraclip billing

[Nivens]

Curious how this is being handled other places. We have been providing solo doc coverage and TEE guidance for these procedures, but due to staffing issues it's becoming increasingly difficult. At most other places I've worked, a cardiologist has done the imaging and we've covered the anesthesia along with other EP/cath lab cases, but it isn't the culture here. The problem is unlike an OR case, it's a solid couple of hours where the doc is tied to that echo, so QZing a CRNA and having the doc pop in and out to do the echo so we can bill for it isn't even an option.

Does your CT group do the TEE for Mitraclip? Do you bill for the TEE and anesthetic, or just anesthetic? Does your group get any sort of subsidy to cover the opportunity cost of covering these cases solo? If so, how was that number determined?

Happy to discuss over PM if more comfortable!

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[T-burglar]

We cover them and it’s a nightmare with our staffing shortages. We only bill the anesthetic since we do the whole case ourselves. we get no subsidy for freeing cardiology from this responsibility lol

 

[FiO2@21]

Not sure how helpful this is, but where I did my training they made the TEE and GA attendings separate. They'd stick a resident or CRNA in that OR doing the case while the cardiac anesthesiologist would handle the TEE. I imagine they billed for both.

 

[midazzoler]

We got cardiologists covering the TEE.

Once the cardiologists were out of town and one of our cardiac trained anesthesiologists was asked to do the case and the echo so they wouldn’t have to cancel. Just because to the layout of the room and issues with the patient we ended up calling an audible and had a second provider take over managing the patient while the CV fellow trained doc stayed on the echo. Since then the managers make sure a body is dedicated to pt management and a second body on the echo. I think if the room was designed better it would be possible to do one provider. On the other hand you do lose the ability to bill for echo so we have no incentive. Also the cardiologists don’t want to miss out on their charges.

 

[psychbender]

We do solo physician providing the anesthetic, and a cardiologist does the TEE. If we could bill for the echo, I imagine we might do it differently.

 

[psychbender]

We do solo physician providing the anesthetic, and a cardiologist does the TEE. If we could bill for the echo, I imagine we might do it differently.

 

[sevoflurane]

Mainly do solo Clips and we perform TEE.
It’s bundled unless there is a second Md doing the anesthetic.

 

[Bertelman]

Our practice is supervision. We have one MD staff with an anesthetist. Separate MD does TEE. We bill for the anesthetic and the TEE.

And yes, it is absolutely part of our discussion when contracts are negotiated. I am a hospital employee. Many of the cardiologists are hospital employees. So cardiac anesthesia freeing up a cardiologist to go bill more is beneficial to the hospital in a couple different ways.

 

[abolt18]

Mainly do solo Clips and we perform TEE.
It’s bundled unless there is a second Md doing the anesthetic.

What does "bundled" mean? As in, you bill insurance for a total amount that includes the anesthetic and TEE together? Or is the hospital paying you some amount to do it?

 

[sevoflurane]

I means exactly that. You get paid for structural heart case. You don’t bill for TEE when you are doing both.

 

[sevoflurane]

It’s all in the relative value guide book for anesthesia. ASA needs to carve out extra reimbursement for TEE like a cabg or valve case.

 

[sevoflurane]

Not worth it to have an extra anesthesiologist in there. It’s like an extra $200.
As someone else mentioned… also not worth it for cardiology when they can be reading echo’s every 5 minutes.

 

[dchz]

If your hospital isn't paying for the service line to your satisfaction. Then you need to find a hospital that will.

 

[abolt18]

I means exactly that. You get paid for structural heart case. You don’t bill for TEE when you are doing both.

Does that mean you're just not getting paid for the TEE? Aka the reimbursement would be the same if the cardiologist was doing the echo?

 

[nimbus]

If your hospital isn't paying for the service line to your satisfaction. Then you need to find a hospital that will.

https://www.cardiovascular.abbott/content/dam/bss/divisionalsites/cv/cv-live-site/hcp/reimbursement/structural-heart/SH-MitraClip-Coding-Guide.pdf

We provide a 2nd anesthesiologist to do echo for these cases if there is one available. This was considered charity work for the benefit of the program. But recently we haven’t had a spare anesthesiologist.

And wow, ICE is $71.

 

[james775]

View attachment 375320View attachment 375321View attachment 375322

https://www.cardiovascular.abbott/content/dam/bss/divisionalsites/cv/cv-live-site/hcp/reimbursement/structural-heart/SH-MitraClip-Coding-Guide.pdf

We provide a 2nd anesthesiologist to do echo for these cases if there is one available. This was considered charity work for the benefit of the program. But recently we haven’t had a spare anesthesiologist.

And wow, ICE is $71.

How can anyone justify 71 dollar reimbursement lol.

 

[sevoflurane]

Does that mean you're just not getting paid for the TEE? Aka the reimbursement would be the same if the cardiologist was doing the echo?

yup

 

[sevoflurane]

But to be honest, MC’s can be challenging and requires a certain level of echo skills to do. So we like doing them… even if we don’t get paid any extra for the echo.
Also cards would much rather be reading echo’s as it’s far more lucrative for them.

 

[abolt18]

yup

Okay haha. I was confused by "bundled". Why not just say "we don't get paid anything extra to do the echo."?

 

[T-burglar]

Can’t wait until this procedure is rarely done any more, it’s based on a defunct surgical procedure and imaging for it can be a complete pain in the ass . Research and development will **** out some complete replacement technology for native valve MR at some point and clips will rarely be done any more and I can’t wait

 

[PpfSuxTube]

Clips take can take forever with almost continuous tee, expert level tee that often the cardiologists can't provide. Nonsense if you're not getting paid for both anesthesia and the tee. Very labour intensive for the echocardiographer

 

[T-burglar]

It really is looking to me like there will be very little heart surgery in the future.

Even the LIMA to LAD will fall to advanced PCI and all that will be left is cath lab catastrophes and heart failure for the surgical team

 

[PpfSuxTube]

Can’t wait until this procedure is rarely done any more, it’s based on a defunct surgical procedure and imaging for it can be a complete pain in the ass . Research and development will **** out some complete replacement technology for native valve MR at some point and clips will rarely be done any more and I can’t wait

I kind of agree. I do them, just to keep my skills up and stay relevant but I'm exhausted at the end of that day and don't make as much as my regular day doing more straightforward cardiac cases

 

[PpfSuxTube]

It really is looking to me like there will be very little heart surgery in the future.

Even the LIMA to LAD will fall to advanced PCI and all that will be left is cath lab catastrophes and heart failure for the surgical team

No chance. Absolutely 0. You just need to find an area with lots of immigrants from south Asia...

 

[sevoflurane]

Okay haha. I was confused by "bundled". Why not just say "we don't get paid anything extra to do the echo."?

I hear what you are saying, but it is actually bundled in the relative value guidelines… weather you do the echo or not.
If you’ve never picked up a RVG anesthesia book, it’s worth a look.
For open heart cases there are like 4 different codes.

 

[sevoflurane]

I think 99355 is the structural heart RVG and it requires a separate sonographer for it to get reimbursed.

 

[sevoflurane]

 

[anaesthetic]

Can’t wait until this procedure is rarely done any more, it’s based on a defunct surgical procedure and imaging for it can be a complete pain in the ass . Research and development will **** out some complete replacement technology for native valve MR at some point and clips will rarely be done any more and I can’t wait

Clips take can take forever with almost continuous tee, expert level tee that often the cardiologists can't provide. Nonsense if you're not getting paid for both anesthesia and the tee. Very labour intensive for the echocardiographer

Anecdotally, I have not been impressed with neither the quality of the MitraClips being placed (severe MR improved to mod-severe MR, some questionable deployments of extra clips, mitral stenosis after deployment, etc.) nor the speed at which these clips are being deployed, at my hospital at least. Also, the cardiologists are generally ungrateful for our 4-6 hour, continuous, advanced level TEEs while doing the anesthetic, because somehow, when the case is scheduled to go past 3pm, suddenly none of their cardiology colleagues are available to do the echo. No thanks.

But to be honest, MC’s can be challenging and requires a certain level of echo skills to do. So we like doing them… even if we don’t get paid any extra for the echo.
Also cards would much rather be reading echo’s as it’s far more lucrative for them.

If you're good at something, never do it for free.

 

[T-burglar]

We got cardiologists covering the TEE.

Once the cardiologists were out of town and one of our cardiac trained anesthesiologists was asked to do the case and the echo so they wouldn’t have to cancel. Just because to the layout of the room and issues with the patient we ended up calling an audible and had a second provider take over managing the patient while the CV fellow trained doc stayed on the echo. Since then the managers make sure a body is dedicated to pt management and a second body on the echo. I think if the room was designed better it would be possible to do one provider. On the other hand you do lose the ability to bill for echo so we have no incentive. Also the cardiologists don’t want to miss out on their charges.

There is an incentive though, that anesthesiologist that’s only doing TEE could be generating an order of magnitude more revenue in the OR

 

[vector2]

It really is looking to me like there will be very little heart surgery in the future.

Even the LIMA to LAD will fall to advanced PCI and all that will be left is cath lab catastrophes and heart failure for the surgical team

PCI, no matter how advanced it gets, will likely never come close to LIMA-LAD. Even if a stent was perfect (i.e. say it was equivalent to a cloned biologic replacement of that diseased segment), there is still a bunch of atherosclerosis (or potential for atherosclerosis) downstream to where the stent is. LIMA-LAD bypasses not just the lesion but the entire segment of prone-to-atheroma coronary proximal to the anastomosis.

The real replacement for LIMA-LAD (and PCI) will be some revolutionary medical advance in GDMT (like tirzepatide appears to be for obesity).

 

[T-burglar]

Multiple sequential stents are possible, CTO treatment is in its infancy but advancing, biocompatibility advances have the potential to eliminate the need for DAPT in the future, there is nothing that a graft does that a stent cannot (in theory).

But I agree a drug that prevents or regresses coronary atherosclerosis might be what comes first

 

[T-burglar]

Also I don’t know why you say a graft bypasses the diseased segment but a stent doesn’t. Can you explain that? Grafts and stents do exactly the same thing, bypass discrete atherosclerotic lesions. In fact long or multiple stents are probably better at revascularizing long complex lesions than a graft

 

[PpfSuxTube]

Also I don’t know why you say a graft bypasses the diseased segment but a stent doesn’t. Can you explain that? Grafts and stents do exactly the same thing, bypass discrete atherosclerotic lesions. In fact long or multiple stents are probably better at revascularizing long complex lesions than a graft

You are not incorrect to state this but it really depends on the patient and whether they have complex triple vessel disease and or comorbidies especially diabetes.
The evidence suggests these are treated differently, with very different outcomes

 

[vector2]

Multiple sequential stents are possible, CTO treatment is in its infancy but advancing, biocompatibility advances have the potential to eliminate the need for DAPT in the future, there is nothing that a graft does that a stent cannot (in theory).

But I agree a drug that prevents or regresses coronary atherosclerosis might be what comes first

Also I don’t know why you say a graft bypasses the diseased segment but a stent doesn’t. Can you explain that? Grafts and stents do exactly the same thing, bypass discrete atherosclerotic lesions. In fact long or multiple stents are probably better at revascularizing long complex lesions than a graft

Multiple sequential stents (especially in small, calcified vessels) are almost certainly inferior to arterial grafting. Indeed, one of the strongest predictors of target lesion fixation failure is the length of stent required

And again, PCI and a LIMA are not bypassing *the same length* of artery. PCI bypasses *just* the target lesion. A LIMA bypasses both that target lesion and a good bit of "normal" coronary. For instance, a 45yo with familial HLD, DMII with 90% prox LAD gets PCI. Only the target lesion gets opened. The entire rest of the length of his LAD over the next 10-30 yrs is still prone to further progression of atherosclerosis plus the risk of plaque rupture even in lesions that are non-obstructive.

OTOH, say he gets a LIMA-LAD. The anastomosis isn't going to be immediately right after the target lesion. It's going to be mid-LAD, which means not only is he protected from obstructive symptomatology in his prox 90%, but also half his LAD distribution is protected from future CAD and plaque rupture.

Furthermore, stents will never be superior to LIMA because LIMA is living tissue. LIMA, in addition to providing more blood flow, has an active endothelium which secretes nitric oxide, prostacyclins, and other mediators which both vasodilate and inhibit platelet aggregation.

https://www.mayoclinicproceedings.org/article/S0025-6196(22)00586-9/fulltext

 

[vector2]

Apropos of the current discussion, nice talk from Sabik, Svensson, Girardi, and MacGillivray on why the STS/AATS did not endorse the 2021 Coronary Revascularization Guidelines.

Coronary Revascularization Guideline: Why STS and AATS Did Not Endorse | STS

Senior leaders from STS and the American Association for Thoracic Surgery discuss the concerns that informed the decision not to endorse the 2021 Guideline for Coronary Artery Revascularization published in December by the American College of Cardiology, American Heart Association, and Society...

www.sts.org

 

[Bertelman]

How can anyone justify 71 dollar reimbursement lol.

Because the cardiologist performing ICE is already billing for the procedure.

Same way you get charged less for adding something to your steak than you would ordering that separately

 

[Bertelman]

Anecdotally, I have not been impressed with neither the quality of the MitraClips being placed (severe MR improved to mod-severe MR, some questionable deployments of extra clips, mitral stenosis after deployment, etc.) nor the speed at which these clips are being deployed, at my hospital at least. Also, the cardiologists are generally ungrateful for our 4-6 hour, continuous, advanced level TEEs while doing the anesthetic, because somehow, when the case is scheduled to go past 3pm, suddenly none of their cardiology colleagues are available to do the echo. No thanks.

I can see where this impression is coming from. But I can tell you it’s all about the quality of your implanter and guidance from the Abbott rep.

I have worked with 4-5 implanters at our hospital. 1 was trash, but this was 9 years ago. We had a surgeon that was average. I’ve got two cardiologists that are average, and one that is superb.

I’m talking 30 min from access to deployment, add 15 min if we do a second clip. Routinely gets a 2-grade reduction with a MG of 4 or less. Last one I did, was Mod-severe down to trace with two clips adjacent to each other.

 

[T-burglar]

I’m not sure where you got that abstract but if it’s from SYNTAX then it’s old and not performed with the current generation of PCI platforms.. Even FAME 3 didn’t really answer the question because the freedom from MACE at one year was pretty damn close in my opinion for both CABG and PCI, and in that trial did NOT use IVUS guided PCI which improves outcomes. The CABG group in FAME3 also bled a lot more (obviously) and ended up with more post op dysrrhythmias and rehospitalization and stroke . Not to mention mandatory recovery from open heart surgery which is unavoidable.

Also although I hate to bring this up, You have to also consider how politicized science and medicine is. The best you can say is that the data, if you take it at face value, “supports” CABG when the vessels are awful candidates for PCI (this will not last forever). And the resistance to other conclusions may have political motivations .

The fact of the matter is CABG involves cracking chests and risking stroke, new dysrrhythmic disorders, and pain and suffering far in excess of PCI, for not-yet truly proven superiority in CAD. I exercise every day, and I cannot continue to be an anesthesiologist if I have a massive stroke. If I develop an Impossible to ablate atrial arrhythmia as a result of my atriotomy I will be really unhappy. Given my choices today, I personally would have a PCI in almost all circumstances.

 

[T-burglar]

I want it to be true as much as the next cardiac anesthesiologist that heart surgery still has a place, because I like big interesting cases just like you. But as time goes on and transcatheter interventions improve, it’s becoming clear that this is just better. I would probably never have an open SAVR at this point. I would rather go home within 24 hrs and immediately feel relief, rather than get readmitted with a fib or a sternal wound infection.

 

[sevoflurane]

I want it to be true as much as the next cardiac anesthesiologist that heart surgery still has a place, because I like big interesting cases just like you. But as time goes on and transcatheter interventions improve, it’s becoming clear that this is just better. I would probably never have an open SAVR at this point. I would rather go home within 24 hrs and immediately feel relief, rather than get readmitted with a fib or a sternal wound infection.

We don’t know what long term TAVR/MC is atm. MC def need long term f/u and valve in valve in valve has a lot more time before we really know. SAVR will always be here.

 

[nimbus]

We don’t know what long term TAVR/MC is atm. MC def need long term f/u and valve in valve in valve has a lot more time before we really know. SAVR will always be here.

Depends on the patient. If they are 90yo with multiple comorbidities, does long term really matter? Sometimes these procedures are palliative.

 

[sevoflurane]

Depends on the patient. If they are 90yo with multiple comorbidities, does long term really matter? Sometimes these procedures are palliative.

Nope. Does on the 35 y/o bicuspid.

 

[sevoflurane]

 

[sevoflurane]

We are just now starting to see 5,10, 15 year outcomes.

 

[sevoflurane]

I am not so sure about MC’s. Def. an older population procedure. Surgical MVR is a lot more satisfying in most cases.

 

[vector2]

I’m not sure where you got that abstract but if it’s from SYNTAX then it’s old and not performed with the current generation of PCI platforms.. Even FAME 3 didn’t really answer the question because the freedom from MACE at one year was pretty damn close in my opinion for both CABG and PCI, and in that trial did NOT use IVUS guided PCI which improves outcomes. The CABG group in FAME3 also bled a lot more (obviously) and ended up with more post op dysrrhythmias and rehospitalization and stroke . Not to mention mandatory recovery from open heart surgery which is unavoidable.

Also although I hate to bring this up, You have to also consider how politicized science and medicine is. The best you can say is that the data, if you take it at face value, “supports” CABG when the vessels are awful candidates for PCI (this will not last forever). And the resistance to other conclusions may have political motivations .

The fact of the matter is CABG involves cracking chests and risking stroke, new dysrrhythmic disorders, and pain and suffering far in excess of PCI, for not-yet truly proven superiority in CAD. I exercise every day, and I cannot continue to be an anesthesiologist if I have a massive stroke. If I develop an Impossible to ablate atrial arrhythmia as a result of my atriotomy I will be really unhappy. Given my choices today, I personally would have a PCI in almost all circumstances.

@sevoflurane posts regarding the nebulous longer-term outcomes of TAVR are almost identical to the issues that plague PCI.

I've been hearing about how the next generation stent will be the latest and greatest thing for the last 15 years, and yet while the outcomes in the short-term in complex patients are equivocal (due to the periop risks of CABG), CABG is significantly better at 5, 10, 15, 20 years, etc. Because of the aforementioned advantages of using living arterial tissue as a graft.

Wrt FAME 3, literally every investigator was dead certain that PCI was going to be non-inferior to CABG when they were designing the trial, and yet:

Overall results found the primary endpoint of death, MI, stroke or repeat revascularization was 10.6% in the PCI group compared with 6.9% in the CABG group at one year. In addition, the incidence of death, MI, or stroke was 7.3% in the FFR-guided PCI group compared with 5.2% in the CABG group.

FAME 3: FFR-Guided PCI vs. CABG in Patients With Three-Vessel CAD - American College of Cardiology

www.acc.org

Marc Ruel, MD (University of Ottawa Heart Institute, Canada), said the results of the trial took him by surprise.

“Personally, I was wrong,” he told TCTMD. “I really thought that the 1-year results of FAME 3 would show noninferiority. I’d been saying this to many people because when you look at SYNTAX, FREEDOM, NOBLE, and EXCEL—the four main trials [comparing CABG versus PCI]—the event curves start separating at 2 to 3 years. In SYNTAX, there was no difference at 1 year. In EXCEL, there was no difference, same with NOBLE. In FREEDOM, it took 2 or 3 years for the curves to separate.”

Given the early separation of the event curves in FAME 3, Ruel, like Kirtane, expects the difference in clinical outcomes will be even more pronounced in long-term follow-up.

In terms of why FAME 3 failed to show PCI was noninferior to surgery, Ruel said surgeons are getting better at performing the procedure, with an increased focus on reducing the risk of adverse events, particularly the risk of stroke. The surgical techniques used by operators in FREEDOM and SYNTAX are now outdated, he added, noting that since those trials were published the surgical community has initiated sweeping quality-improvement initiatives.

FAME 3: PCI Fails to Demonstrate Noninferiority to Surgery in Three-Vessel CAD

(UPDATED) Interventionalists and surgeons call it a big win for CABG surgery, especially since its advantages were seen so early.

www.tctmd.com

And maybe IVUS helps, maybe it doesn't. There are not a bunch of large, randomized trials establishing that. Hence why it's a class II recommendation. Same as FFR, except FFR/iFR probably has an order of magnitude more trials establishing its utility.


Where we agree is that CABG needs to evolve. We don't do open cholecystectomies any more, so given technological advancement it's just not reasonable to expect that CTS is absolved of having to learn complex endoscopic and robotic techniques. I'm almost 40 years old. I have a very strong family history of CAD. Like you, I do not want a sternotomy, but I think that's it's essentially inarguable that anything is going to confer a longer long-term survival advantage than a LIMA-LAD.

I think by the time I need a CABG, if GDMT has not cured CAD or the propensity for plaques to rupture, I suspect I will be getting a hybrid procedure (TECAB or MIDCAB for the LIMA-LAD + PCI to the other lesions)

 

[PpfSuxTube]

Imo there's no way pci will ever overtake cabg. I've got 25 years left, not in my career I don't think...
We see dudes from early 1980s that had their cabg and are still coming back for tha tka etc etc...

And guys that had pci last year, back in with a jammer...

Total anecdote but so what

 

[Robotic Wis-Hipple]

There is an incentive though, that anesthesiologist that’s only doing TEE could be generating an order of magnitude more revenue in the OR

Every hospital wants to build a structural heart program. Ask yourself why? It’s because every watchman or TAVR valve is 30k for the hospital. Every catheter an EP doc put in the pt, every ICE catheter etc is thousands. Sure the professional fees aren’t great but the hospital is cleaning up.

Don’t just provide a service in good faith for the hospital, especially at an opportunity cost of a cardiac trained doc doing a couple $200 TEEs per day for your watchman’s/MitraClips. Negotiate at a minimum the docs day rate for coverage, if they say no guess they don’t get to do these cases. There’s a reason the cardiologists walk away from procedural guidance. Everyone in the department and admin knows this is the case, don’t give your work away for free so the hospital and cardiology can make their most efficient dollars.

 

[Bertelman]

My hospital has realized Watchman aren’t nearly as profitable as they thought. By the time they charge the Baylis, perclose, etc. they have lost most of their margin

 

[dchz]

My hospital has realized Watchman aren’t nearly as profitable as they thought. By the time they charge the Baylis, perclose, etc. they have lost most of their margin

Why do they perclose a vein? Just put a suture and stopcock.