Lack of proper reimbursement is hampering adoption of minimally invasive gastrointestinal endoscopy in North America

Abstract

Endoscopic submucosal dissection (ESD) and related procedures are minimally invasive and cost-effective alternates to surgery. However, there is no approved or listed current procedural terminology (CPT) for ESD. We aimed to review the current reimbursement process hurdles for ESD procedures in private practice model in United States. We reviewed the data of two advanced endoscopists (one in New York and other in Pennsylvania State) performing ESD in their private practice set-ups. We found the reimbursement process was complex, with number of refusals varied from 0-9 for ESD procedures. It was not paid at all in 8.3% of cases by the medical insurance. Endoscopic mucosal resection, which is considered inferior as compared to ESD, but has a listed CPT, was denied in only 0.83% cases. Our data highlights the billing hurdles by the endoscopists to adopt ESD-related procedures in private practice model.

Keywords: Endoscopic submucosal dissection; Lack of reimbursement; Current procedural terminology; Minimally invasive gastrointestinal endoscopy; North America

Core tip: Despite being minimally invasive and cost-effective alternates to surgery for removal of large gastrointestinal mucosal lesions, Endoscopic submucosal dissection has no approved or listed current procedural terminology for billing. It leads to much higher denial rate by the health insurance companies in North America. This scenario is highlighted in our article and is a hurdle in adoption of such useful techniques in private practice set-up.