Medicare Reimbursement for Balloon Catheter Dilations Among Surgeons Performing High Volumes of the Procedures to Treat Chronic Rhinosinusitis | Medical Devices and Equipment | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Figure 1.  Number of Balloon Catheter Dilations and Reimbursement Amount
Number of Balloon Catheter Dilations and Reimbursement Amount

A, The number of allowed balloon catheter dilations performed between 2011 and 2017. B, The total amount Medicare paid for balloon catheter dilations between 2011 and 2017.

Figure 2.  Mean Medicare Reimbursement for Balloon Catheter Dilations by Year
Mean Medicare Reimbursement for Balloon Catheter Dilations by Year
Figure 3.  Data on Surgeons Performing High Volumes of Balloon Catheter Dilation Procedures
Data on Surgeons Performing High Volumes of Balloon Catheter Dilation Procedures

A, The percentage of all balloon catheter dilations performed by ear, nose, and throat (ENT) surgeons performing high volumes of procedures. B, The number of ENT surgeons performing high volumes of procedures. C, The median number of balloon dilations performed by ENT surgeons performing high volumes of procedures.

Figure 4.  The Percentage of Ear, Nose, and Throat Surgeons Who Performed High Volumes of Balloon Catheter Dilation Procedures by State (2016)
The Percentage of Ear, Nose, and Throat Surgeons Who Performed High Volumes of Balloon Catheter Dilation Procedures by State (2016)
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    Original Investigation
    January 23, 2020

    Medicare Reimbursement for Balloon Catheter Dilations Among Surgeons Performing High Volumes of the Procedures to Treat Chronic Rhinosinusitis

    Author Affiliations
    • 1Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
    JAMA Otolaryngol Head Neck Surg. 2020;146(3):264-269. doi:10.1001/jamaoto.2019.4357
    Key Points

    Question  What is the trend in balloon catheter dilation use to treat chronic rhinosinusitis among otolaryngologists, specifically in regard to surgeons performing high volumes of these procedures?

    Findings  This retrospective analysis of Medicare databases found that there has been a 486% increase in the total number of balloon catheter dilations performed between 2011 and 2017 and a 270% increase in the number of otolaryngologists who performed more than 10 such procedures per year between 2012 and 2016.

    Meaning  The number of balloon catheter dilation procedures continues to rise yearly, with surgeons who perform high volumes of these procedures performing most dilations.

    Abstract

    Importance  Chronic rhinosinusitis is among the most common and costly conditions treated by physicians. After failure of medical treatment, surgical intervention in the form of endoscopic sinus surgery is traditionally offered. Balloon catheter dilation (BCD) has become a less-invasive alternative with increasing popularity among otolaryngologists.

    Objective  To evaluate the most recent BCD data in the Medicare population, with a specific focus on the percentage of procedures performed by surgeons who perform high volumes of this procedure, their reimbursements, and their national geographic distributions.

    Design, Setting, and Participants  This retrospective review included data from 2011 through 2017 from Medicare Part B National Summary Data Files and Medicare Provider Utilization and Payment Data. Patients with procedures including Current Procedural Terminology codes 31295 (maxillary sinus dilation), 31296 (frontal sinus dilation), and 31297 (sphenoid sinus dilation) were included.

    Exposures  Balloon catheter dilation of the paranasal sinuses.

    Main Outcomes and Measures  Total and mean reimbursements over time to physicians for BCDs, as well as the percentage of BCDs performed by and reimbursed to ear, nose, and throat (ENT) surgeons who perform high volumes of BCDs (>10 procedures) in a given year.

    Results  The total number of BCDs rose from 7496 in 2011 to 43 936 in 2017 (a 486% increase). The overall reimbursement increased from $11 773 049 in 2011 to $63 927 591 in 2017 (a 433% increase). From 2012 to 2016, ENT surgeons who performed high volumes of the procedures rose from 101 to 382 surgeons (a 270% increase). In 2016, 25 214 of 41 960 BCDs (60.1%) were performed by ENT surgeons performing high volumes of the procedure, compared with 5603 of 13 109 procedures (42.7%) in 2012. In a line of best fit, at the 75th percentile of procedure volume, there was an increase of 4.2 BCDs in the median number of procedures done per physician per year, compared with an increase of 1.5 BCD procedures per physician per year in the line of best fit for the 50th percentile.

    Conclusions and Relevance  Balloon catheter dilation continues to increase in popularity among otolaryngologists treating chronic rhinosinusitis. Most BCDs are performed by ENT surgeons who perform high volumes of the procedure.

    Introduction

    Affecting up to 15% of the adult American and European population, chronic rhinosinusitis (CRS) represents one of the most common and costly pathologies seen by physicians.1 In the United States alone, CRS accounts for more than 14 million clinic and emergency department visits annually.1 Paranasal sinus balloon catheter dilation (BCD), a minimally invasive alternative to endoscopic sinus surgery (ESS), has become a popular treatment option for CRS since its approval by the US Food and Drug administration in 2005. Balloon catheter dilation offers the advantages of decreased recovery time, minimized postoperative care, and performance under local anesthesia.2 Acceptance of BCD has continued to grow, with multiple studies showing it to be a safe and effective procedure.3,4

    Quiz Ref IDDistinct Current Procedural Terminology (CPT) coding was introduced for BCD surgeries in 2011, allowing national claims-based database analyses for such procedures. These have shown a significant yearly rise in both the number of BCD procedures and the amount of BCD reimbursements.5,6 This development exists despite relative stability in the total number of sinus surgeries performed.7

    The Medicare national database has been used to assess evolving trends in BCDs. This database includes the number of yearly procedures and their compensation, as well as information on clinicians who have performed more than 10 yearly BCD procedures. Svider et al8 recently described use of BCD from 2011 to 2015 using this data set, illustrating the marked increase in BCD’s popularity. The objective of this study is to evaluate the most recent BCD data in the Medicare population, with a specific focus on the percentage of procedures performed by clinicians who complete high volumes of this procedure and their reimbursements, as well as national geographic distributions.

    Methods

    Annual procedure data for BCDs was obtained from the Part B National Summary Data Files (calendar years 2011-2017) using the CPT codes 31295 (balloon dilation of the maxillary sinus ostium), 31296 (balloon dilation of the frontal sinus ostium), and 31297 (balloon dilation of the sphenoid sinus ostium).9 Earlier years were not used, because the balloon sinus surgery CPT codes were introduced in 2011.10 Because multiple bills may be submitted for the same procedure through the use of modifiers, such as 80S (specifying a bill by an assistant surgeon) or SG (specifying a bill from an ambulatory surgical center), the category called other was used (instead of the category total) to represent the true number of procedures and more accurately capture case numbers and payments to surgeons.9 From these numbers, mean US dollar amounts paid to surgeons were calculated by dividing amount paid by the number of procedures. We also aggregated all the data for each of the 3 procedures to create a total reimbursement for all BCD procedures.

    The study was determined to be exempt from review by the Yale Human Investigation Committee because the information is publicly available. Informed consent procedures were therefore not required.

    We obtained further data from the Medicare Provider Utilization and Payment Data: Physician and Other Supplier files (calendar years 2012-2016) using the aforementioned CPT codes.11 This file contains data on all health care professionals who billed for a given procedure greater than 10 times in a given year, as well as the number of services performed. We defined otolaryngologists performing high volumes of procedures (HV ENT physicians) as those performing more than 10 BCD procedures in a year. This threshold was chosen because of practicality within the data limitations, and because, even as such, only 100 to 400 HV ENT physicians were found in each year analyzed, amounting to less than 5% of all represented ENT physicians in this data set (approximately 8572 in 2016). We excluded all nonphysicians, including registered nurses, physician assistants, and surgery centers (which may bill for multiple clinicians). In cases where physicians were listed twice (because they performed the procedure in both a facility and office setting), data were merged. The total number of HV ENT physicians was calculated for each procedure, as well as their mean number of procedures. Furthermore, the number of otolaryngologists in each state was estimated by the unique ENT physicians listed in the 2016 Medicare Provider Utilization and Payment Data: Physician and Other Supplier file.

    The percentage of BCDs performed by HV ENT physicians per year was calculated by dividing the aggregated number of procedures performed by HV ENT physicians (derived from the 2016 Medicare Provider Utilization and Payment Data: Physician and Other Supplier files) by the total number of procedures allowed by Medicare (derived from the Part B National Summary Data Files). The total number of procedures by HV ENT physicians was compared with the total number of ENT physicians in a given state to calculate the percentage of ENT physicians who can be identified as HV ENT physicians. It is important to note that, for this calculation, we included any physician who performed more than 10 of any of the 3 BCD procedures. Additionally, the median and interquartile range (IQR) for the mean number of BCDs (aggregating all 3 procedures) performed by HV ENT physicians each year were calculated. (Of note, if a physician was identified as a HV ENT physician by performing more than 10 maxillary BCD procedures, for example, but 10 or fewer frontal sinus BCD procedures, we were unable to include those numbers.)

    Similar methodology was used to identify surgeons performing high volumes of endoscopic surgery (HV ESS surgeons), using the CPT codes 31256 (maxillary sinus), 31276 (frontal sinus), and 31287 (sphenoid sinus). We characterized the mean number of ESS procedures performed by HV ESS surgeons. Furthermore, we cross-referenced the HV ENT surgeons performing BCDs with HV ESS surgeons to see how many of the first group also performed more than 10 ESS surgeries, and of those, what number of procedures they perform.

    Data analysis occurred from April 2019 to October 2019. Graphs were created in Microsoft Excel 2018 (Microsoft Corporation). The map was created using mapchart.net.

    Results
    Growth in Number and Reimbursement of BCD Procedures

    Quiz Ref IDThe number of Medicare-reimbursed BCD procedures rose considerably between 2011 and 2017, from a total of 7496 sinus ostium BCD performed in 2011 to 43 936 procedures in 2017 (Figure 1A). There was a growth of 486% in the 7-year period, with a linear line of best fit suggesting an increase of 6541.6 cases per year (R2, 0.95). Most of this increase was observed between 2011 through 2013, because the number of procedures rose by more than 70% both between 2011 (7496 procedures) and 2012 (13 109 procedures) and between 2012 and 2013 (23 051 procedures). In recent years, the number of procedures has only gradually increased, with a growth of 7.1% growth between 2015 (39 193 procedures) and 2016 (41 960 procedures) and 4.7% between 2016 and 2017 (43 936 procedures). Sphenoid sinus BCDs (2011, 1377 procedures; 2014, 7391 procedures; 2017, 11 635 procedures) were consistently performed less frequently than maxillary BCDs (2011, 2910 procedures; 2014, 12 698 procedures; 2017, 15 972 procedures) and frontal BCDs (2011, 3209 procedures; 2014, 12 712 procedures; 2017, 16 329 procedures).

    As the number of BCD procedures substantially increased between 2011 and 2017, so did reimbursements provided by Medicare. The overall reimbursement has grown from $11 773 049 in 2011 to $63 927 591 in 2017, representing a 433% increase. From 2013 onward, the mean rate of reimbursement per procedure has remained relatively constant (2013, $1519; 2017, $1455), although there was a fall in the reimbursement of frontal and sphenoid sinus ostium BCDs in 2012 (mean reimbursements: frontal BCD: 2011, $2096; 2012, $1544; 2013, $1937.44; sphenoid BCD: 2011, $1521; 2012, $967; 2013, $1169) (Figure 2).

    Surgeons Performing High Volumes of BCD Procedures

    Quiz Ref IDWe found that 5603 of 13 109 procedures (42.7%) performed in 2012 were performed by HV ENT physicians. This number increased each year, to 12 574 of 23 051 procedures (54.5%) in 2013 and 19 048 of 32 801 procedures (58.1%) in 2014; it stabilized at 23 714 of 39 193 procedures (60.5%) in 2015 and 25 214 of 41 960 procedures (60.1%) in 2016 (Figure 3A). We found a nationwide growth of 278.2% in the number of physicians performing more than 10 of at least 1 type of balloon surgery, from 101 surgeons in 2012 to 382 surgeons in 2016 (Figure 3B). Regarding the median number of procedures performed by HV ENT physicians, a linear line of best fit suggests an increase of 1.5 procedures a year (R2, 0.68) (Figure 3C). However, on examination of the 75th percentile of physicians in a linear line of best fit, there seemed to be an increase in 4.2 procedures a year between 2012 and 2016 (R2, 0.74).

    In a geographic distribution of HV ENT physicians in each state, Florida (59 of 521 ENT physicians [11.3%]), Kansas (7 of 68 [10.3%]), New Mexico (5 of 45 [11.1%]), Nevada (5 of 42 [11.9%]), and Texas (67 of 622 [10.8%]) had the highest proportions of HV ENT physicians (Figure 4). The top 5 states with the largest absolute numbers of HV ENT physicians were Texas (67 of 622 ENT physicians), Florida (59 of 521), California (32 of 773), New York (20 of 681), and Georgia (16 of 264).

    Details of the Number of BCD and ESS Surgeries Done by HV ENT Surgeons

    Quiz Ref IDIn 2016, we found 382 surgeons who performed high volumes of BCD procedures; these clinicians performed a median of 46 (IQR, 28-75) maxillary, frontal, and sinus BCD surgeries (combined) for the Medicare population. We identified 274 ENT physicians in 2016 who performed more than 10 maxillary, frontal, or sphenoid endoscopic sinus surgeries (HV ESS ENT physicians), performing a mean 17 (IQR, 13-32) ESS procedures on the Medicare population. Of the 382 HV ENT physicians, only 37 physicians (9.7%) were also identified as HV ESS surgeons. These 37 surgeons performed a median of 19 (IQR, 13.5-31.5) ESS procedures and 56 (IQR, 32.5-73.5) BCD surgeries.

    Discussion

    Chronic rhinosinusitis accounts for more than 13 billion dollars in health care costs annually in the United States.12,13 It is treated with a combination of nasal steroids, saline sprays, antibiotics, and systemic steroids.14 After failure of appropriate medical therapy surgical intervention is offered, which has historically consisted of ESS,12 BCD offers a minimally invasive alternative in treating medically refractory CRS with similar efficacy and outcomes.

    Through data reported through 2017, our findings demonstrate a continuous rise in the number of BCD procedures performed in the Medicare population since the introduction of a specific BCD CPT code in 2011. Almost 44 000 procedures were performed in 2017 compared with about 7500 procedures reported in 2011, an approximate 6-fold increase (Figure 1A). This trend is similar to that shown by Svider et al8 in their comparison of BCD use rates relative to ESS. The corresponding payments were more than 60 million dollars (Figure 1B), representing a 433% increase in payments over a 7-year span. With relatively stable procedure reimbursements during this time, this increase in total Medicare payments solely represents an increase in the number of BCD procedures performed (Figure 4).

    As the number of overall BCD performed has risen, the percentage of BCD procedures performed by HV ENT physicians has also escalated annually (Figure 3A). In 2016, the most current year recorded for HV ENT physicians, 60.1% of all BCDs were performed by HV ENT surgeons. Furthermore, the number of physicians performing more than 10 BCDs has risen 278% since 2012 (Figure 3B). Although the specific reasoning for this increase is beyond the scope of this study, greater familiarity with BCD procedures and a growing body of literature on the safety and efficacy of BCDs offer possible explanations.

    Among all HV ENT physicians, there appeared to be a mean increase of 1.5 BCDs performed yearly. However, within the 75th percentile of volume, a more significant increase of 4.2 BCDs per year was seen (Figure 3C). When analyzing HV ENT physicians further, it was noted that less than 10% of HV ENT physicians also performed high volumes of ESS procedures. The designation as a HV ENT physicians, specifically in regard to BCDs (by definition), is therefore unlikely to be secondary to an increase in overall sinus surgery volume. Once more, the reasoning behind this cannot be ascertained based on these data, although it too may be secondary to greater comfort with BCDs among the surgeons performing them more regularly.

    Limitations

    Although this study provides up-to-date insight into the trend of BCDs, there are limitations. Quiz Ref IDThis study uses only Medicare data, which, although representing the largest health care payer in the United States, fails to include procedures performed through other insurance providers. Furthermore, Medicare patients are mostly made up of patients 65 years and older and may not be representative of the general population. Also, Medicare does not disclose data on physicians billing 10 or fewer procedures. Finally, included numbers are underestimated; if a physician was identified as a HV ENT physician by performing more than 10 maxillary BCD procedures, for example, but 10 or fewer frontal sinus procedures, we were unable to include those numbers. Despite these limitations, this study provides valuable insight into the increased use of BCDs over the past 8 years.

    Conclusions

    Paranasal sinus BCD use has continued to grow annually, with more than 60 million dollars in Medicare reimbursement in 2017. The ENT surgeons who perform high volumes of these procedures account for more than half of all BCDs performed in the United States. Additional studies outside of the Medicare population are warranted to appreciate the overall use of BCD in treating CRS.

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    Article Information

    Accepted for Publication: November 19, 2019.

    Corresponding Author: R. Peter Manes, MD, Yale New Haven Hospital, Yale University School of Medicine, 800 Howard Ave, 4th Floor, New Haven, CT 06519 (rpeter.manes@yale.edu).

    Published Online: January 23, 2020. doi:10.1001/jamaoto.2019.4357

    Author Contributions: Drs Kasle and Torabi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Kasle, Torabi, Manes.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Kasle, Torabi, Narwani.

    Critical revision of the manuscript for important intellectual content: Kasle, Narwani, Manes.

    Statistical analysis: Kasle, Torabi, Manes.

    Administrative, technical, or material support: Kasle, Narwani.

    Supervision: Kasle, Manes.

    Conflict of Interest Disclosures: None reported.

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