Medicare Reimbursement Trends for Interventional Radiology Procedures: 2012 to 2020.

PURPOSE: To investigate the reimbursement trends for interventional radiology (IR) procedures from 2012 to 2020. MATERIALS AND METHODS: Reimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for 20 common IR procedures. The authors then investigated compensation trends after adjusting for inflation and from the unadjusted data between 2012 and 2020. RESULTS: From 2012 to 2020, the mean unadjusted reimbursement for procedures decreased by -6.9% (95% confidence interval [CI], -13.5% to -0.34%). This trend was even more profound after inflation was taken into account, with a mean decline in adjusted reimbursement of -18.7% (95% CI, -24.4% to -12.9%) during the study period, with a mean yearly decline of -2.8%. The difference between the mean unadjusted and adjusted payment amounts was significant (P = .012). Similarly, linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2012 to 2020 (R2 = 0.97), indicating a steady decline in reimbursement over time. CONCLUSIONS: In just under a decade, IR has experienced significant reimbursement cuts by Medicare, as demonstrated by both the unadjusted and inflation-adjusted payment trends. Knowledge of these trends is critically important for practicing interventional radiologists, leaders within the field, and legislators, who may play a role in formulating future reimbursement schedules for IR. These data may be used to help support more amenable reimbursement plans to sustain and facilitate the growth of the specialty.

Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology.

PURPOSE: To assess and quantify the financial effect of unbundling newly unbundled moderate sedation codes across major payors at an academic radiology practice. MATERIALS AND METHODS: Billing and reimbursement data for 23 months of unbundled moderate sedation codes were analyzed for reimbursement rates and trends. This included 10,481 and 28,189 units billed and $443,257 and $226,444 total receipts for codes 99152 (initial 15 minutes of moderate sedation) and 99153 (each subsequent 15 minute increment of moderate sedation), respectively. Five index procedures-(i) central venous port placement, (ii) endovascular tumor embolization, (iii) tunneled central venous catheter placement, (iv) percutaneous gastrostomy placement, and (v) percutaneous nephrostomy placement-were identified, and moderate sedation reimbursements for Medicare and the dominant private payor were calculated and compared to pre-bundled reimbursements. Revenue variation models across different patient insurance mixes were then created using averages from 4 common practice settings among radiologists (independent practices, all hospitals, safety-net hospitals, and non-safety-net hospitals). RESULTS: Departmental reimbursement for unbundled moderate sedation in FY2018 and FY2019 totaled $669,701.34, with high per-unit variability across payors, especially for code 99153. Across the 5 index procedures, moderate sedation reimbursement decreased 1.3% after unbundling and accounted for 3.9% of procedural revenue from Medicare and increased 11.9% and accounted for 5.5% of procedural revenue from the dominant private payor. Between different patient insurance mix models, estimated reimbursement from moderate sedation varied by as much as 29.9%. CONCLUSIONS: Departmental reimbursement from billing the new unbundled moderate sedation codes was sizable and heterogeneous, highlighting the need for consistent and accurate reporting of moderate sedation. Total collections vary by case mix, patient insurance mix, and negotiated reimbursement rates.

Institutional Variability in Patient Radiation Doses ≥5 Gy During Percutaneous Coronary Intervention.

OBJECTIVES: The aim of this study was to evaluate institutional variability in high radiation doses during percutaneous coronary intervention (PCI). BACKGROUND: It is unknown whether radiation safety practices are optimally applied across institutions performing PCI. METHODS: Using data from a large statewide registry, PCI discharges between July 1, 2016, and March 31, 2018, with a procedural air kerma (AK) recorded were analyzed. PCI procedures were grouped by the performing hospital, and institutional frequency of procedural AK ≥5 Gy was calculated. Fitted hierarchical Bayesian modeling was performed to identify variables independently associated with an AK ≥5 Gy. The performing hospital was included as a random effect in the hierarchical model. RESULTS: Among 36,201 PCI procedures at 28 hospitals, procedural AK was ≥5 Gy in 1,477 cases (4.1%), ≥10 Gy in 185 (0.5%), and ≥15 Gy in 105 (0.3%). The institutional frequency of procedural AK ≥5 Gy ranged from 0.0% to 10.9%. Bayesian modeling identified body mass index, dyslipidemia, diabetes, prior coronary bypass surgery, use of mechanical circulatory support, and the performing hospital as independent predictors of an AK ≥5 Gy. The median odds ratio for the performing hospital, representing an estimate of the contribution of interhospital variability in determining the odds of having a procedural AK ≥5 Gy, was 3.08 (95% confidence interval: 3.01 to 3.16). CONCLUSIONS: Wide variability exists in the institutional frequency of procedural AK ≥5 Gy during PCI. After accounting for patient characteristics and procedural variables, the performing hospital appears to be a major factor in determining patient radiation dose in contemporary PCI.

Transcatheter Dialysis Conduit Procedures: Changing National and State-Level Medicare Use Patterns over 15 Years.

PURPOSE: To evaluate the changing use of transcatheter hemodialysis conduit procedures. METHODS: Multiple Centers for Medicare & Medicaid Services datasets were used to assess hemodialysis conduit angiography. Use was normalized per 100,000 beneficiaries and stratified by specialty and site of service. RESULTS: From 2001 to 2015, hemodialysis angiography use increased from 385 to 1,045 per 100,000 beneficiaries (compound annual growth rate [CAGR], +7.4%)]. Thrombectomy use increased from 114 to 168 (CAGR, +2.8%). Angiography and thrombectomy changed, by specialty, +1.5% and -1.3% for radiologists, +18.4% and +14.4% for surgeons, and +24.0% and +17.7% for nephrologists, respectively. By site, angiography and thrombectomy changed +29.1% and +20.7% for office settings and +0.8% and -2.4% for hospital settings, respectively. Radiologists' angiography and thrombectomy market shares decreased from 81.5% to 37.0% and from 84.2% to 47.3%, respectively. Angiography use showed the greatest growth for nephrologists in the office (from 5 to 265) and the greatest decline for radiologists in the hospital (299 to 205). Across states in 2015, there was marked variation in the use of angiography (0 [Wyoming] to 1173 [Georgia]) and thrombectomy (0 [6 states] to 275 [Rhode Island]). Radiologists' angiography and thrombectomy market shares decreased in 48 and 31 states, respectively, in some instances dramatically (eg, angiography in Nevada from 100.0% to 6.7%). CONCLUSIONS: Dialysis conduit angiography use has grown substantially, more so than thrombectomy. This growth has been accompanied by a drastic market shift from radiologists in hospitals to nephrologists and surgeons in offices. Despite wide geographic variability nationally, radiologist market share has declined in most states.

Characterizing the Impact of Women in Academic IR: A 12-Year Analysis.

PURPOSE: To determine the representation of female interventional radiology (IR) investigators and elucidate possible gender-specific disparities. MATERIALS AND METHODS: We analyzed 4,884 original, peer-reviewed articles from 2006-2017 in the Journal of Vascular and Interventional Radiology and CardioVascular and Interventional Radiology. Data abstraction and statistical analysis were performed for first and senior author gender, citations, and grants. RESULTS: We found that 84% of first authors and 91.4% of senior authors were male (P < .01). No significant difference was observed versus expected in terms of author gender collaboration combinations (P = 1.00). Each year reflected a 0.3%-0.4% increase in articles published by women (first author: B-value: 0.3, P = .05; senior author: B-value: 0.4, P = .01). No difference was observed in citations or grants received between genders. Female authors received increasing citations and grants each year (citations: first author: B-value: 0.24, P = .05; senior author: B-value: 0.16, P = .15; grants: B-value: 0.88, P = .02). CONCLUSIONS: Women are equally as productive as men as determined by metrics such as number of publications, citations, and grants and are proportionally represented in the literature. No data indicating collaborative or citation/grant discrimination were observed, suggesting that the academic IR community is inclusive of its female constituents and equally respects their research contributions. Based on the statistically significant increases in female authorship observed in this 12-year study, this article reports encouraging trends for the future of women in interventional radiology.

Interventional nephrology: current status and clinical impact in Japan.

BACKGROUND: Current status and clinical significance of interventional nephrology has not been reported from Japan. METHODS: Questionnaires were mailed twice to the directors of all 534 Japanese certificated nephrology training institutions in 2014. The main questions were current performance, categorized annual procedure volume and managers of peritoneal dialysis (PD) access, vascular access (VA) surgery, endovascular intervention, and kidney biopsy. Frequencies of nephrologist involvement between high volume center and low volume center and association between the level of nephrologists' involvement to each procedure and annual procedure volume were examined. RESULTS: 332 (62.2%) institutions answered performance of all procedures and 328 (61.4%) institutions answered all procedure volume. Kidney biopsy, VA surgery, endovascular intervention and PD access surgery were performed by any doctors in 94.2, 96.3, 88.4, and 76.2% and each involvement of nephrologist was 93.9, 54.1, 53.1 and 47.6%, respectively. Cochran-Armitage analyses demonstrated significant increases in all 4 procedure volume with greater management by nephrologists (p < 0.01). Nephrologists involvement to VA surgery associated with procedure volume increase in not only VA surgery, but also PD catheter insertion (p < 0.01) and kidney biopsy (p < 0.05). And nephrologists involvement to PD catheter insertion also associated with surgical volume increase in both VA surgery (p < 0.01) and endovascular intervention (p < 0.05). CONCLUSIONS: Main manager of all 4 procedures was nephrologist in Japan. Each procedure volume increased as nephrologists become more involved. Acquisition of one specific procedure by nephrologist associated with increase not only in this specific procedure volume, but also the other procedure volume.

From interventionist imaging to intraoperative guidance: New perspectives by combining advanced tools and navigation with radio-guided surgery. / De la imagen intervencionista a la guía intraoperatoria: nuevas perspectivas combinando herramientas avanzadas y navegación con la cirugía radioguiada.

The integration of medical imaging technologies into diagnostic and therapeutic approaches can provide a preoperative insight into both anatomical (e.g. using computed tomography, magnetic resonance imaging, or ultrasound), as well as functional aspects (e.g. using single photon emission computed tomography, positron emission tomography, lymphoscintigraphy, or optical imaging). Moreover, some imaging modalities are also used in an interventional setting (e.g. computed tomography, ultrasound, gamma or optical imaging) where they provide the surgeon with real-time information during the procedure. Various tools and approaches for image-guided navigation in cancer surgery are becoming feasible today. With the development of new tracers and portable imaging devices, these advances will reinforce the role of interventional molecular imaging.

Enteral Access Procedures: An 18-Year Analysis of Changing Patterns of Utilization in the Medicare Population.

PURPOSE: To evaluate national trends in enteral access and maintenance procedures for Medicare beneficiaries with regard to utilization rates, specialty group roles, and sites of service. MATERIALS AND METHODS: Using Medicare Physician Supplier Procedure Summary Master Files for the period 1994-2012, claims for gastrostomy and gastrojejunostomy access and maintenance procedures were identified. Longitudinal utilization rates were calculated using annual enrollment data. Procedure volumes by site of service and medical specialty were analyzed. RESULTS: Between 1994 and 2012, de novo enteral access procedure utilization decreased from 61.6 to 42.3 per 10,000 Medicare Part B beneficiaries (-31%). Gastroenterologists and surgeons performed > 80% of procedures (unchanged over study period) with 97% in the hospital setting. Over time, relative use of an endoscopic approach (62% in 1994; 82% in 2012) increased as percutaneous (21% to 12%) and open surgical (17% to 5%) procedures declined. Existing enteral access maintenance services increased 29% (from 20.1 to 25.9 per 10,000 beneficiaries). Radiologists (from 13% to 31%) surpassed gastroenterologists (from 36% to 21%) as dominant providers of maintenance procedures. Emergency physicians (from 8% to 23%) and nonphysician providers (from 0% to 6%) have seen rapid growth as maintenance services providers as these services have transitioned increasingly to the emergency department setting (from 18% to 32%). CONCLUSIONS: Among Medicare beneficiaries, de novo enteral access procedures have declined in the last 2 decades as existing access maintenance services have increased. The latter are increasingly performed by radiologists, emergency physicians, and nonphysician providers.

IR and the Sunshine Act: Two-Year Analysis of the Open Payments Database and Comparison with Related Specialties.

PURPOSE: To characterize medical industry-based payments made to US-based interventional radiology (IR) physicians, identify trends in compensation, and compare their payment profile with those of other related specialties, including vascular surgery (VS) and interventional cardiology (IC). Payments made to orthopedic surgery (OS) physicians are reported as a historical control. MATERIALS AND METHODS: For each group, the total payment number, amount, and mean and median numbers and amounts were calculated. The data were then reanalyzed after correcting for statistical outliers. For IR, VS, and IC, leading industry sponsors, payment amount, and differences in payments from 2013 to 2014 were highlighted. Payments to IR were grouped by category and geographic location. The Kruskal-Wallis test was used for statistical analysis. RESULTS: A total of $26,857,622 went to 1,831 IR physicians, representing 70.9% of active IR physicians, and the corrected mean payment was $597 ± 832.2 (standard deviation). The respective values were $18,861,041, 3,383, 80.6%, and $851.59 for VS; $32,008,213, 7,939, 78.6%, and $417.16 for IC; and $357,528,020, 21,829, 77.8%, and $598.48 for OS. OS had the largest number of payments (295,465 vs 24,246 for IR, 84,635 for VS, and 160,443 for IC) and greatest total payment amount. VS had a significantly higher corrected median payment amount ($463; P < .0001) than IR ($214) and IC ($99). Covidien and Sirtex Medical were the leading industry sponsors to IR, and 64.6% of IR payments were compensation for services other than consulting. There was no significant difference in median payment received per geographic region (P = .32). CONCLUSIONS: OS received the largest number and total payment amount, and VS received a significantly greater corrected median payment amount, versus IR and IC. As the Open Payments program continues to be implemented, it remains to be seen how this information will affect relationships among physicians, patients, and industry.

Medicare Utilization of CT Angiography from 2001 through 2014: Continued Growth by Radiologists.

PURPOSE: To examine changes in utilization of computed tomography (CT) angiography nationally and changing relative specialty roles in examination interpretation. MATERIALS AND METHODS: Service-specific claims data for region-specific CT angiography examinations were identified using Medicare Physician Supplier Procedure Summary Master Files from 2001 through 2014. Longitudinal national utilization rates were calculated using annual Medicare enrollment data for 2001-2013. Procedure volumes by specialty group and site of service were analyzed. RESULTS: Total annual claims for CT angiography for Medicare fee for service beneficiaries increased from 64,846 to 1,709,088 (compound annual growth rate [CAGR] 29%) between 2001 and 2014. Per 1,000 beneficiaries, overall CT angiography utilization increased annually from 2.1 in 2001 to 47.6 in 2013. Overall interpretation market share increased 4% (91%-95%) for radiology. Cardiology increased from 1% in 2001 to 6% in 2007 but decreased annually to 2% in 2014. Vascular surgery market share remained < 1% throughout the study period. Growth of CT angiography in the emergency department (ED) outpaced all other sites of service, increasing from 11% to 28% (CAGR 38%). The chest was the dominant body region imaged with CT angiography, increasing from 36,984 to 914,086 (CAGR 28%). CONCLUSIONS: Utilization of CT angiography in the Medicare population increased markedly for 2001-2014, particularly in the ED, with radiologists remaining dominant providers. The chest is the most common body region imaged with CT angiography.

Transarterial Chemoembolization in the Coming Era of Decreased Reimbursement for Readmissions.

PURPOSE: CMS has identified readmission of patients within 30 days of discharge as a targeted quality metric and has instituted financial penalties to encourage hospitals to reduce readmissions. The aims of this study were to examine the rate of 30-day admissions after transarterial chemoembolization (TACE) at a single institution and to identify potential factors associated with readmission. METHODS: A total of 275 patients were identified who underwent a total of 457 TACE procedures over a 21-year period. Their electronic medical records were reviewed to evaluate the 30-day readmission rate in all patients undergoing TACE, and multiple logistic regression analysis was used to ascertain any clinical or demographic factors affecting the risk for readmission. RESULTS: Nineteen patients (4.2%) required readmission to the hospital within 30 days; 11 of these readmissions were directly attributable to TACE, with inpatient stays upon readmission ranging from 2 to 27 days. Fourteen patients (3.1%) returned to the emergency department (ED) within 30 days of TACE. Medicare patients were more likely to be readmitted to the hospital or require emergency department treatment within 30 days than patients with private health insurance (P = .006). Patients with worse performance status (Eastern Cooperative Oncology Group) were also more likely to require emergency department care within 30 days (P = .04). CONCLUSIONS: TACE patients are at risk for readmission, often related to underlying medical comorbidities. Although extensively studied in other specialties, the Hospital Readmissions Reduction Program has received little attention in the radiology literature, and radiologists should familiarize themselves with this continually expanding initiative.

Revenue Potential for Inpatient IR Consultation Services: A Financial Model.

PURPOSE: Interventional radiology (IR) has historically failed to fully capture the value of evaluation and management services in the inpatient setting. Understanding financial benefits of a formally incorporated billing discipline may yield meaningful insights for interventional practices. MATERIALS AND METHODS: A revenue modeling tool was created deploying standard financial modeling techniques, including sensitivity and scenario analyses. Sensitivity analysis calculates revenue fluctuation related to dynamic adjustment of discrete variables. In scenario analysis, possible future scenarios as well as revenue potential of different-size clinical practices are modeled. RESULTS: Assuming a hypothetical inpatient IR consultation service with a daily patient census of 35 patients and two new consults per day, the model estimates annual charges of $2.3 million and collected revenue of $390,000. Revenues are most sensitive to provider billing documentation rates and patient volume. A range of realistic scenarios-from cautious to optimistic-results in a range of annual charges of $1.8 million to $2.7 million and a collected revenue range of $241,000 to $601,000. Even a small practice with a daily patient census of 5 and 0.20 new consults per day may expect annual charges of $320,000 and collected revenue of $55,000. CONCLUSIONS: A financial revenue modeling tool is a powerful adjunct in understanding economics of an inpatient IR consultation service. Sensitivity and scenario analyses demonstrate a wide range of revenue potential and uncover levers for financial optimization.

Interventional oncology research in the United States: slowing growth, limited focus, and a low level of funding.

PURPOSE: To establish the characteristics of published interventional oncology (IO) research, including the volume, growth, geographic distribution, type of research, and funding patterns, and to determine how IO research compares with overall radiology research. MATERIALS AND METHODS: This retrospective bibliometric analysis of public data was exempt from Institutional Review Board approval. IO articles published between 1996 and 2008 were identified in the National Library of Medicine MEDLINE database. Country of origin, article methodology, study topic, and source of funding were recorded. Growth was analyzed by using linear and nonlinear regression. RESULTS: Total journal articles numbered 3801, including 847 (22.3%) from the United States, 722 (19.0%) from Japan, and 390 (10.3%) from China. World publications grew with a sigmoid (logistic) pattern (predicted maximum of 586.8 articles per year, P < .001). The United States and China also had logistic and slowing growth (maximums of 111.0 and 48.1 articles per year, respectively; both P < .001). Growth was linear in Japan (growth of 3.0 articles per year, P < .001) and exponential and accelerating in Germany, Italy, South Korea, France, and the United Kingdom. The United States produced 187 (36.9%) review articles but only 52 (13.1%) clinical trials. Japan (75, 18.8%) and China (71, 17.8%) both produced more clinical trials than other countries. U.S. IO articles were less likely than general radiology articles to receive funding from government (12.5% vs 23.7%) and nongovernment (15.0% vs 17.0%) sources. Liver cancer articles constituted 2388 (62.8%) of all IO articles. CONCLUSION: IO research is slowing in the United States but growing elsewhere. Japan and China are leaders in clinical trial research. U.S. IO research receives less funding than does overall radiology research. IO research focuses primarily on liver cancer.

Peripheral arterial interventions: trends in market share and outcomes by specialty, 1998-2005.

OBJECTIVE: Vascular surgeons (VS), interventional cardiologists (IC), and interventional radiologists (IR) perform peripheral arterial interventions (PAI). In this study, we reviewed market share trends and compared outcomes for each specialty using the National Inpatient Sample (NIS). METHODS: Patient discharges for PAI (1998-2005) were identified based on ICD9-CM procedure codes. The provider's specialty was identified by a specialty-specific algorithm and analyzed using SAS 9.1 (SAS Institute, Cary, NC). Market share trends and distribution of cases at teaching versus non-teaching hospitals were evaluated. Primary outcome measures were in-hospital mortality and iatrogenic arterial injuries (IAI). Multivariate logistic regression was performed to identify independent predictors of post-procedure morbidity and mortality. RESULTS: The number of cases identified was 23,825. From 1998 to 2005, IR's market share decreased six-fold (1998: 33% to 2005: 5.6%) whereas VS market share increased from 27% to 43% and IC from 10% to 29% (P < .05). A similar but more pronounced trend was observed at teaching hospitals. In-hospital mortality rate was highest for IR (2.1 IR% vs 1.2% VS and 0.6% IC; P < .001). Post-procedure IAI was highest in the IC group (1.3% vs IR 0.9% and 0.5% VS; P < .05). Compared with VS, the mortality rate was 1.62 times higher for IR patients (odds ratio [OR]: 1.62, 95% confidence interval [CI]: 1.16-2.24) and IAI was 2.44 times higher for IC (OR: 2.44, 95% CI: 1.63-3.66) and 1.75 times higher for IR (OR: 1.75, 95% CI: 1.08-2.81) patients. CONCLUSIONS: IR market share of PAI has precipitously declined while those of VS and IC have increased significantly. Vascular surgeons had the lowest overall morbidity and mortality of all groups. Increase in the number of endovascularly-trained VS with better access to fluoroscopy units may further increase VS's market share.