Trend to Watch: ASCs Are Adding Interventional Radiology

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By: Joe Paone | Senior Editor

Published: 10/4/2022

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Catheter-based diagnosis and treatment of a variety of conditions are providing attractive alternatives to more invasive procedures.


Interventional radiology (IR) is slowly finding its way into ASCs. IR physicians perform a wide variety of “pinhole surgeries” — minimally invasive procedures that leverage catheters, wires, needles and sheaths — using image guidance provided by fluoroscopy, ultrasound, CT or MRI. They can interpret images in real time and use them to perform therapeutic procedures that traditionally have been open or laparoscopic in nature. In a sense, IR physicians function simultaneously as radiologists and surgeons. Proponents say IR procedures are less risky and less painful with shorter recoveries than traditional surgeries. They are often performed using sedation rather than general anesthesia.

In many cases, IR physicians focus on cardiovascular issues, but they can also perform a wide variety of procedures that touch on other specialties. The British Society of Interventional Radiology offers a breakdown of IR treatments:

 

• Blood vessel disease. IR physicians treat peripheral vascular disease using techniques such as balloon angioplasty or stents to stretch narrowed arteries or, to avoid limb amputation, infuse clot-busting drugs into the artery via catheter. They can also treat aneurysms and hemorrhages using stent grafts.

• Veins. IR physicians prevent pulmonary embolisms by placing inferior vena cava filters to capture blood clots or using catheter tubes to break them up. They also treat varicose veins through laser or microwave heat treatments, drugs or embolization techniques, and blocked veins via thrombolysis or stents.

• Non-vascular conditions. Sometimes referred to as interventional oncology, IR physicians focus on diseases in the liver, kidney and uterus. This includes treating tumors or cancers through ablation and embolization; removing blockages caused by the effects of cancer; draining fluid or pus in the chest or abdomen; placing feeding tubes; and treating collapsed spinal bones via vertebroplasty.

• Stone diseases. IR physicians attack kidney stones through nephrostomy, which involves placing a tube in the kidney to allow urine to drain while removing the stones through instrumentation. They treat gallstones by placing a catheter tube through the liver to remove the stones or place stents.

IR could make sense as a service line addition at ASCs in states where regulatory conditions allow it. Its close alliance with cardiovascular medicine dovetails with the current trend of bringing cath labs and associated procedures to ASCs.

Last year, Comprehensive Surgical Care (CSC) opened its flagship ASC in Gilbert, Ariz. The 15,000-square-foot multispecialty facility features three ORs — one outfitted as a cath lab with a ceiling-mounted C-arm, the other two with mobile C-arms — and a hot lab for Y-90 procedures. CSC has since opened additional ASCs across the Midwest and has plans to add several more facilities in California, Oregon, Idaho and Arizona.

CSC founder Joel Rainwater, MD, whose areas of specialty include peripheral vascular disease and interventional oncology, says IR has evolved since he completed training. “It used to be considered a subspecialty within the general radiology training track,” he says. “The training has become more specialized and unique as its own separate pathway.”

IR has always been comparable to surgery, according to Dr. Rainwater. “The specialty has grown in scope,” he says. “I now see more interventional radiologists behaving more like their surgical colleagues. They’re seeing patients, developing and implementing treatment plans and following up with patients.”

Dr. Rainwater typically performs transcatheter treatment of primary and metastatic liver cancers. “We place an angiographic catheter into the hepatic artery supply and inject the treatment directly into the liver, a method that accomplishes a much higher concentration into the target volume of the tumors,” he says.

 
NEW CONCEPT The opening of WellSpan Health’s first outpatient interventional radiology facility is the first step in the system’s plan to provide this type of care in convenient locations for patients.  |  WellSpan Health

The transcatheter injection method is a more focused cancer treatment that can increase the tumor kill ratio and minimize the amount of treatment that goes into tissues such as the stomach or the nerves, a benefit that could limit complications associated with systemic chemotherapy.

CSC’s IR physicians also perform limb preservation procedures for patients with severe peripheral artery disease that puts their limbs at risk for gangrene, ulcerations or even amputation. “Using X-ray and ultrasound guidance, we attack blocked arteries, remove the plaque and restore the vessel to flowing condition,” says Dr. Rainwater. He also performs thermal ablation therapies, which involve placing a probe about the size of a very small knitting needle into a tumor or growth and applying energy to freeze or coagulate the tissue, causing it to undergo cell death.

Dr. Rainwater believes IR has enormous potential for a variety of conditions. “We access organs with imaging guidance — whether that’s fluoroscopy, CT scan, ultrasound or in some cases MRI — to target a treatment, executing it with just a tiny puncture or a small incision,” he says. “That allows the patient to have shorter downtime, often no requirement for hospital admission or overnight stay and a much quicker recovery.”

CSC isn’t alone in capitalizing on IR’s growth potential. In June, WellSpan Health opened its first outpatient IR practice in Chambersburg, Pa., to perform minimally invasive, wide-awake outpatient  vascular procedures. Interventional cardiologist James Harvey III, MD, MSc, FACC, FSCAI, vice president and chief medical officer of the heart and vascular service line and director of the Structural Heart Program at WellSpan, says the development of the center focused on interdisciplinary collaboration and patient comfort and convenience.

“The main drivers are patient preference and better care,” says Dr. Harvey, who calls the facility a joint clinic that diagnoses and treats disease because of a team-based approach by interventional cardiologists and interventional radiologists. “We know there’s clearly overlap of what they can do,” he says. “Historically, these entities worked in isolation, but there’s a broader breadth of skill sets when they work together. We’re treating a disease process as opposed to what each individual specialty would do on its own.”

WellSpan is currently focused on diagnosing and treating peripheral vascular disease and plans to utilize the outpatient IR model at other facilities in its coverage area. “We have some forward-thinking leaders here, and we’ll be adding the specialty across our health system,” says Dr. Harvey. 

Wellspan’s efforts are part of a larger movement taking place across the country as ASC leaders are realizing that adding IR increases access to needed care for patients and positions their facilities to capitalize on the future potential of a promising service line. OSM

Reimbursements Could Increase Outpatient Opportunities
PAYMENT POLICIES

CMS and other insurers are coming around to paying for interventional radiology (IR) procedures performed in the ASC environment, but reimbursements remain unsteady. “It’s difficult to know which procedures are possible and which are disallowed,” says Joel Rainwater, MD, founder of Comprehensive Surgical Care (CSC) in Gilbert, Ariz. “It’s a constant battle to stay up to date on where the payers are going.”

CMS has added percutaneous coronary interventions (PCI) to the ASC-approved list, and CSC is rolling out that service at its ASCs. “There’s a tremendous amount of pressure on CMS and payers to lower the cost of episodes of care,” says Dr. Rainwater. “It doesn’t make sense for insurers to overpay for a PCI or a liver cancer therapy if they can save money and get just as good if not better outcomes from ambulatory settings.”

Under the 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule, CMS is set to increase ASC reimbursement rates by 2.7%. C. Matthew Hawkins, MD, FSIR, health policy and economics division councilor at the Society of Interventional Radiology (SIR), says CMS has also proposed combining often-performed code pairs into HCPCS C codes, which will be paid at a higher rate to account for a complexity adjustment. “The premise is to make the procedures more equitable in hospitals and ASCs,” says Dr. Hawkins. “It’s also designed to create similar payment policies for the same procedures, regardless of where they take place.”

Establishing comparable payments in ASCs and hospitals will allow some procedures to shift to ambulatory facilities, according to Dr. Hawkins. He says this will create additional capacity in hospitals, adding, “It’s possible the proposal to add complexity adjustments to payments will move more IR cases into the outpatient setting.”             

— Joe Paone

On the Web

The Society of Interventional Radiology provides an analysis of Medicare’s 2023 Hospital Outpatient Prospective Payment System and ASC Payment System Proposed Rule (sirweb.org/coding) as well as a CPT code impact analysis of both rules (osmag.net/SIR2023).

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