Since the introduction of fiber-optic colonoscopy in the 1960s, advancements in the field of complex snare polypectomy have progressed considerably. With the addition of ultrasound and advanced imaging techniques such as narrow band imaging and chromoendoscopy, large polyps can now be accurately assessed and deemed appropriate for endoluminal resection. Whereas previously, these polyps were predominantly referred for surgical resection, new information regarding lesion morphology has now allowed for increased use of endoscopic removal techniques. However, this advancement has not been associated with a corresponding shift in reimbursement dollars to reflect the increased work associated with these complicated endoscopic resections. As it stands, reimbursement for endoscopic resections lags far behind that for colectomies, leading to a disproportionate number of these lesions being removed by the more invasive techniques involving a colectomy. Rather than utilizing the benefits and tools available with the modern colonoscope (such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), combined endolaparoscopic surgery (CELS), and full-thickness laparoendoscopic excision (FLEx)), many colorectal surgeons are bypassing these techniques in favor of a colectomy. While training and skill are some reasons for doing so, this manuscript seeks to investigate ways in which reimbursement barriers are mitigated, to thereby allow a broader application of these unique procedures to patients.

From 2006 to 2020, the average reimbursement by centers for Medicare and Medicaid services (CMS) has decreased by 11% 1. Coupled with an average inflation rate during this period of 1.8% per year, the cumulative price increase due to inflation over this period is 28.3%. This leads to a cost to reimbursement differential of nearly 40%! Jesse M. Ehrenfeld, MD, president of the American Medical Association noted recently in an interview that “When adjusted for inflation in practice costs, Medicare physician pay declined 26% from 2001 to 2023” 2. Certainly not a recipe for success when considering complex endoscopic procedures. And when you consider endoscopic procedures overall, these have been targeted by CMS for declining reimbursement (some as much as 15–20% cuts in the last ten years; see Table 1). However, this decline in reimbursement does not tell the whole story. In a world of pay-for-performance metrics, endoscopic techniques are associated with several distinct benefits, including lower length of stay and reduced complication rates, which may increase their appeal in this environment. A retrospective case–control study evaluated the use of advanced endoscopic techniques to address benign polyps initially referred for “endoscopically unresectable” lesions. 70% of these lesions were successfully removed endoscopically with much lower length of stay and complication rates compared with matched colectomy controls.3 When viewed from this perspective, using endoluminal tools has the potential to save the health system large amounts of money, particularly for benign pathologies. Additionally, patients benefit from colon preservation and the ability to return to work earlier while avoiding the morbidity of a colectomy.

Billing and coding topics are in general poorly understood by many physicians going into practice. However, these are essential to the success of a complex endoscopic practice. There are some important tips that may increase the payments for endoscopic procedures, which requires some background. This next section will explore how reimbursement models work, including a few specific examples.

In order to bill for a procedure, there must be a diagnosis and a procedure. Failure to have both of these will result in non-payment for services. Additionally, there must be agreement between a diagnosis and a procedure (for example, it makes no sense to perform an inguinal hernia repair for the diagnosis of a colon polyp, so this would be denied payment). Diagnoses are currently captured based on the International Classification of Diseases (ICD)-10 system. Procedures are described using numeric codes based on the Current Procedural Terminology (CPT) coding system, which is used by the World Health Organization (including current iterations owned and maintained by the American Medical Association). Common CPT codes include: 46600 (anoscopy), 45300 (rigid proctoscopy), 45330 (flexible sigmoidoscopy), and 45378 (diagnostic colonoscopy). The location where you start matters (as for example, a colonoscopy through the anus has a different code than a scope done through an ostomy). Furthermore, what you do when you get to a lesion also matters (as for example, a polypectomy done by cold forceps biopsy, hot forceps biopsy, submucosal lift/snare, or piecemeal EMR all have different codes). For a further description of examples of these, see Table 1.

Now things start to get complicated. Newer or more advanced procedures (such as ESD) may not always have a procedure code associated with it. If you perform one of these, you either use an unlisted code (e.g. 45399 for colon or 45999 for rectum). These unlisted codes must be used with caution, depending on your reimbursement system, as they are associated with zero work RVU's, but may have higher reimbursement based on contractual negotiations with payors). Unlisted codes must be accompanied by a cover letter with any claim, that explains the nature of the procedure, equipment used, estimated practice cost, and a comparison of physician work to those of other comparable services where there is an established value.4 Alternatively, surgeons can use an existing code with a modifier, indicating the procedure was slightly different than what the code describes.

This leaves advanced endoscopists with a difficult decision to make. While the unlisted code (and 0 wRVUs) may not contribute towards a physician's annual compensation, the higher overall reimbursement may be beneficial to the health system. Use of a combination of smaller codes for similar techniques with a -22 modifier (indicating a significantly increased amount of time and effort required to complete it compared to normal) may allow a higher RVU value and associated reimbursement added to a physician's annual salary, but a comparatively lower overall reimbursement to the health system. Neither is a perfect solution. Both can result in significantly decreased reimbursement compared with colectomy.

The process of establishing new codes is equally complex and not necessarily of benefit. To establish or add a new code, all similar codes are systematically reevaluated. This may decrease the reimbursement of these codes, similar to what happened to all GI CPT codes in recent years. Specifically for ESD, in October 2021, a Healthcare Common Procedure Coding System code (C9779) was assigned, which can be considered a precursor to a CPT code. This newer code can now be used for outpatient coding and payment. Sometimes, reimbursement and work value associated with codes are decreased as a group, thereby serving as a further disincentive to creation of any new codes, not to mention performing these procedures outright.

CPT codes are assigned a set value or unit by CMS in the form of RVU, which then allows physicians to be reimbursed based on the RVU assigned to the CPT codes billed for any given procedure. For example, as of 2023, CPT code 46600 (anoscopy) is worth 0.55 RVU, which corresponds to a CMS reimbursement of $95.07. CPT code 45330 (flexible sigmoidoscopy) corresponds to 0.84 RVU with a corresponding CMS reimbursement of $160.70. CPT code 45378 (diagnostic colonoscopy) is worth 3.36 RVU with a corresponding CMS reimbursement of $200.28. Keep in mind these are the physician reimbursement amounts, and there may be additional reimbursements (such as a facility fee paid to an institution) based on where the procedure is performed. The assigned RVU numerical value is supposed to be inclusive of: “the work effort, the practice expense, and the malpractice expense” of a procedure.5

As the complexity of a procedure increases, the more complicated billing and coding becomes. This is the case when an endoscopist utilizes more than one technique to remove a single lesion. Remembering what we said earlier, successful billing requires both a diagnosis and a code. Use of multiple techniques (or procedural codes) on THE SAME diagnosis ICD-10 code would constitute double dipping, which the system does not allow. Similarly, using one technique (CPT code) to address multiple polyps (multiple locations, therefore multiple ICD-10 codes) falls under one CPT code. The additional diagnostic locations cannot be billed separately. However, if TWO different techniques (CPT codes) are used to remove TWO different polyps (at two different locations, with discrete ICD-10 codes for each), then the proceduralist can submit TWO separate bills for each of the corresponding ICD-10/CPT codes (using a modifier -59 or distinct procedural service code).

An important caveat is that each additional procedure will not be reimbursed at the full amount. Instead, reimbursement is adjusted based on the difference between the value of that additional procedure and the base procedure.6 To understand this better, consider adding an extra antenna tower to a skyscraper as an analogy. One does not need to build another skyscraper, as that work is already done. Similarly, adding the second antenna should not include reimbursement for getting to the top of the building, as that part of the work was already performed. Thus, each added procedure must subtract out the intrinsic value of the original procedure. Consider a patient where a surgeon performs a colonoscopy with EMR for a cecal lesion and a colonoscopy with biopsy for a sigmoid polyp (two different techniques for two different polyps done at the same time). The colonoscopy with biopsy is a secondary procedure, which must subtract out the intrinsic work of a diagnostic colonoscopy (as this “work” was already done for the primary procedure or EMR). The EMR itself is not the primary procedure, as that took additional time and effort. Instead, the base of both of these procedures more closely resembles a diagnostic colonoscopy. Table 2 provides some examples of how this type of multiple procedure - payment reduction applies to endoscopy.

Hopefully by now, one starts to realize the potential problems with billing and coding with endoscopy. The topic is much more complex as there are many additional rules. Some procedures are “bundled” (e.g., polyp removal and clip placement) and therefore cannot be billed separately at all. Even if one bills for multiple procedures, the only procedure that will be reimbursed 100% is the one with the highest fee amount. After a few payment reductions, the additional cost of the extra equipment to remove the second, third, or even fourth lesion becomes marginally more expensive, and at some point, costs more than the decreasing reimbursement. This usually occurs somewhere between the 2nd and 3rd technique, depending on the specifics of your cost structure for various equipment pieces.

The challenge for the advanced endoscopist is to find ways in which an advanced endoscopic approach can compete with colectomy, given the disparity between reimbursement for resection and that for a comparable endoscopic procedure (Table 3). When comparing the time, equipment, and resources required, endoscopic procedures may result in a financial loss for the institution (even though patients experience lower complication rates and faster recovery, as previously outlined). The difficulty in billing for ESD/EMR (not to mention the time required to gain expertise) is an impedance for colorectal surgeons to employ these advanced endoscopic maneuvers on a regular basis. For example, compare the work valued by performing a colectomy versus an endoscopic procedure. A right colectomy (CPT codes 44205, 44160) is “worth” between 20 and 23 RVUs and a left colectomy (CPT codes 44204, 44140) is “worth” between 22 and 27 RVUs. That is significantly more than an EMR (CPT code 45390), which is valued at 6.04 RVUs but may take a similar amount of time and effort to workup and perform the procedure. And this is significantly more than the basic endoscopy procedures for the colon (snare, biopsy, etc), which max out at around 3.5 RVUs. Consider the average CMS reimbursement for an EMR (CPT 45390) was $2,569 vs. ESD (Code C9779) was $3,261 (7). Of course these are averages, and private insurance has the potential to reimburse more.

A decision point to consider is WHERE to schedule these procedures. This requires consideration that different endoscopic procedures have different reimbursement profiles depending on the tax ID of the location performed. In general, reimbursements are lower for hospital-based procedures than surgicenter or non-hospital clinic locations, because the payors avoid payment of additional facility fees. When considering where to perform a procedure, one option is to schedule things in the operating room, to allow for use of the full range of available tools (advanced endoscopic approach first, with available CELS, FLEx, and colectomy if initial attempts are unsuccessful). However, this may result in a decreased reimbursement overall. An alternate strategy is to schedule lesions more likely to be successfully removed without laparoscopy in an endoscopy suite instead, particularly one not associated with a hospital tax-ID. This alters reimbursement rates. Consider that for a flexible sigmoidoscopy with snare excision of tumor, CMS reimbursed physicians on average (in 2023) $300 if it was performed in office, $120 if done in a hospital facility, $1,083 if a hospital outpatient and $564 if in a surgicenter.7

Cohan et al (Table 3; discussed below) showed a significant decrease in reimbursement for an endoscopic approach to polyps, despite an overall cheaper overall cost.8 They followed n=90 patients referred for endoscopically unresectable benign colonic polyps, of which 38 proceeded with an “endoscopic step-up approach” (e.g. start with endoscopy, perform EMR, ESD, combined endolaparoscopic procedure as needed, and proceed to colectomy if all are unsuccessful). This was compared with n= 52 patients who underwent a planned colectomy. The authors commented that endoscopic procedures were performed at a financial loss to the institution, however, they concluded that “this does not reflect a number of unmeasured benefits to the patient, the surgeon, and the health care system.” This is a common theme in the literature- that the true benefits of endoscopic removal are not well captured by simply looking at the cost/profit analyses. Wickham et al published data demonstrating endoscopic approaches are associated with distinct benefits over matched colectomy controls (e.t. 4.2% vs. 33.9% complication rates, length of stay 1.13±2.41 vs. 3.89±4.57 days, mortality 0 vs. 0.6%).3 Similarly, Law et al found lower overall cost and higher quality adjusted life years (QALYs) during an economic analysis of endoscopic resection vs. laparoscopic colectomy in patients with complex colon polyps.9 The authors performed a decision-analysis utilizing software models applied to a hypothetical cohort of patients with large polyps. The cost of endoscopic resection was $5,570 per patient and yielded 9.64 additional QALYs. This compares favorably with the cost of laparoscopic colectomy, which is associated with a cost of $18,717 per patient and 9.577 additional QALYs. The main limitation of this study is that the analysis was based on a simulated model based on extracted data from a systematic review of nonpedunculated colon polyps removed via EMR technique, which may not be completely generalizable.

Additionally, Gamaleldin et al published a comparison of advanced endoluminal procedures vs. laparoscopic colectomy for benign colorectal polyps.10 This was a case-matched control study of n=48 patients with ESD compared to n=48 colectomy patients. Length of stay was significantly shorter for ESD (1.5±1.4 vs 5.2±2.4 days, p<0.001), and ESD was associated with a 43% cost-reduction. Jayaram et al published their observational cohort comparing n=11 patients undergoing combined endolaparoscopic surgery for right colon polyps with n=11 patients with conventional laparoscopic right colectomy.11 Calculated total cost for a CELS patient was much cheaper at $5,523.29 vs. $12,626.33 for a laparoscopic colectomy, which was attributed to decreased length of stay and reduced operating room time. These reduced costs must be balanced against reduced reimbursement. Table 3 demonstrates the interplay between cost/reimbursement (Adapted from Cohan et al 2020.8 Across numerous studies, it seems the benefits of using these complex endoscopic or endoluminal surgical procedures are largely focused on benefits to the patient and savings to the health care system, rather than to a hospital unit or individual surgeon.