How Urology Office Procedures Evolved in the Early 2000s: Shifting from TURP to Minimally Invasive Treatments

In the early 2000s, urology office procedures were primarily coded using the American Medical Association's Current Procedural Terminology (CPT) codes, which are part of the Healthcare Common Procedure Coding System (HCPCS) Level I.  

Before 2000, the majority (by total quantity) of in-office procedures performed by a urologist were diagnostic.  In the early 2000s, urology office procedures were primarily coded using the American Medical Association's Current Procedural Terminology (CPT) codes, which are part of the Healthcare Common Procedure Coding System (HCPCS).

Here are some CPT codes that were commonly used for urology office procedures around that time:

• 52000: Cystourethroscopy (separate procedure)

• 52310: Cystourethroscopy with removal of foreign body, calculus, or ureteral stent from urethra or bladder; simple

• 52315: Cystourethroscopy with removal of foreign body, calculus, or ureteral stent from urethra or bladder; complicated

• 52332: Cystourethroscopy with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)

• 51701: Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine)

• 51702: Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)

• 51703: Insertion of temporary indwelling bladder catheter; complicated

• 51798: Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging

• 51741: Complex uroflowmetry (e.g., calibrated electronic equipment)

• 51784: Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique

With CMS granting office-based reimbursement for certain procedures, three therapeutic codes were on the rise in early 2002: interstitial laser coagulation of the prostate (ILC) 52647, transurethral needle ablation (TUNA) 53852, and transurethral microwave thermotherapy (TUMT) 53850.   The combined usage of these three codes led to a total number of in-office BPH procedures of about 30,000 in 2002.   This total equated to the drop in hospital-based transurethral resection of the prostate (TURP) procedures that were occurring during that era (which were ~100,000 TURPs in 1997 and ~70,000 TURPs in 2003). Between 2000 and 2008, the TURP rate among Medicare patients decreased by 47.6%, from 670 to 351 per 100,000 men.

These office-based procedures were not as dramatic in relieving symptoms; the procedures were effective, but not to the level that a TURP would be for flow rates and AUA symptom score assessments. 

So why were they taking share from TURP?  Two reasons: 1) patients were more accepting of the non-hospital setting and potential reduced complication profiles of the procedures (men do not like the prospect of days in the hospital catheterized and then long-term retrograde ejaculation), and 2) resource management (time & money). 

Reimbursement Considerations

Reimbursement rates for these procedures varied based on factors such as geographic location, the setting of the service (e.g., office vs. hospital), and specific payer policies.

The Medicare reimbursement for CPT code 52601—transurethral resection of the prostate (TURP), including control of postoperative bleeding—was approximately $1,139. This amount reflects the national average payment under the Medicare Physician Fee Schedule for that year.  This was not the total cost of a TURP—just the physician payment for the procedure.

The Medicare reimbursement for CPT code 52647—laser coagulation of prostate, including control of postoperative bleeding, complete—in a non-facility (office) setting was calculated using the following Relative Value Units (RVUs):

• Physician Work RVUs: 10.36

• Practice Expense RVUs: 42.87

• Malpractice RVUs: 0.61

• Total Non-Facility RVUs: 53.84

To determine the reimbursement amount, these total RVUs are multiplied by the Medicare conversion factor for that year. In 2002, the conversion factor was $36.1992.

Calculation: 53.84 RVUs × $36.1992 = $1,949.09

Therefore, the approximate Medicare reimbursement for CPT code 52647 performed in an office setting in 2002 was $1,949.09. 

Note: Actual reimbursement may have varied based on geographic adjustments and other factors

 Site of Care Shifts

A urologist could now cycle between the exam rooms of their office and a procedure room in their office to perform BPH procedures.  This eliminated having to deal with the hospital scheduling for these procedures, reduced their inpatient population (thus reducing their round time), and allowed them to offer a procedural option to their hospital-phobic subset of patients (which always seemed to be a fair share of the patients).

Additionally, a TURP was usually at least an hour procedure on the schedule—these in-office procedures could be 30 minutes or less.  Two BPH procedural interventions per hour versus one intervention per hour was not just time savings; it was a doubling of revenue in that same patient care hour.

A study analyzing Medicare claims from 1998 to 2006 found that average total payments for outpatient urological procedures varied widely, with lower costs associated with procedures performed in physician offices compared to hospitals.

Simple Math

A urologist performed a TURP in the hospital and made ~$1,100 in an hour. Or the urologist stayed in the office and made ~$1,900 X 2 for doing two ILCs in that same time.   Unlike in the hospital, for in-office procedures the urologist had to cover the direct supply costs of the procedure.  These direct costs were well under $900 per procedure for ILC. Bottom line, the urologist could double the revenue in that hour for the BPH interventions (and even see other patients in the exam rooms of the office during the downtime in the procedures). 

Takeaways

1)       Follow the money.   Healthcare is a business.  Know the reimbursement codes for the specialties you deal with—know the disparities in payment between types of interventions and sites of care.

2)       In healthcare, time is money when the time is filled with revenue-generating activity.  With physicians being primarily paid for activity (in the American system), if you can increase the throughput of interventions, you have increased physician revenue. A few minutes saved in a day may not matter, but 15 minutes saved can be translated to seeing another patient in an exam room, and 30 minutes can be translated into another procedure performed that day.

3)       Be grateful. Thank you to Kelli Hallas , Jacob Drapkin , and Henry Alder for the many lessons in reimbursement you provided for me.

Next up—the operational and logistical considerations for helping establish office-based BPH treatment programs. 

Sources

HCUP Healthcare Cost & Utilization Project

AHRQ  Agency for Healthcare Research & Quality

PubMed