Physician Reimbursement for Endoscopic Submucosal Dissection: A Single Center Analysis

Abstract

Background and AimsEndoscopic Submucosal Dissection (ESD) has become an established procedure for resection of pre-malignant lesions. Despite its benefits and cost-effectiveness, there are significant challenges to bring ESD to mainstream practice given the unpredictability of reimbursement. ESD is submitted for billing purposes without dedicated Current procedural terminology codes. We analyzed physician component billing and reimbursement data indexed to time, procedure location, and insurance type. MethodsAll physician billing claims and reimbursement data for ESD cases performed between January 2017 and December 2019 in a single tertiary referral center were included. Procedure type was grouped by lesion location: esophageal ESD, gastric and/or duodenal ESD, and colon and/or rectal ESD. To normalize the data, we divided the total dollar payment by the number of hours it took to complete the procedure. ResultsCompleted insurance claims were available for 163 procedures, and 134 met criteria for this study. In our analysis there were 42 government, 92 private insurance payers. The mean charge was $3562.31 for government claims and $3471.33 for private claims. The mean payment was $905.01 (range: $55.64-6140) for government payers, and $1134.24 (range: $44.26-3500) for private payers. The average payment per procedure was $886.43 for esophageal ESD, $732.71 for gastric or duodenal ESD and $1325.35 for colon and/or rectal ESD. The mean $ amount for claims paid for all endoscopic mucosal resection performed in the same time period was $405.50 (range: $106-$1775). ConclusionESD is consistently under-reimbursed across insurance types when compared to surgical alternatives and endoscopist time. With proven efficacy, safety and cost-saving data, appropriate Current procedural terminology codes should be provided for ESD.