Phlebectomy Task Force: Harnessing data to advocate for access to care (by ensuring sustainable payment)

PHLEBECTOMY TASK FORCE: Harnessing data to advocate for access to care (by ensuring sustainable payment)

John Blebea, MD, MBA, FACS and Kenneth Harper, MD, FACS, RPVI, RPhS

As AVLS members are too well aware, officebased payment for many of the core vein procedures that we can offer our symptomatic patients has been in steady decline for over a decade. As part of the Medicare Part B Physician Fee Schedule, when the Resource- Based Relative Value System was introduced almost 30 years ago, Medicare payment rates set the bar for payment in the United States. Over the past 18 months, a group of AVLS members has been working to infuse payment methodology with clinical and data-driven insights. The work has not been simple and has much to accomplish, but the effort stands so far as a work-in-progress on harnessing data to support appropriate payment changes.

SETTING THE SCENE

In early 2018, specialty societies (e.g., AVLS, Vascular Surgery, Interventional Radiology) surveyed physicians who frequently perform phlebectomies to assess their responses regarding the two CPT codes describing the procedure. These survey results were collated and summarized, and a multi-specialty group of physician volunteers presented the data to the RBRVS Update Committee or RUC Panel. Since 1992, the RUC is the venue where specialties present their data and share their expertise about what RVUs they recommend to each CPT typically performed by that specialty. The two codes surveyed for ambulatory phlebectomy Çare 37765 (10-20 incisions) and 37766 (more than 20 incisions). There is no code for less than ten incisions.

As a result of the April 2018 RUC meeting, CMS agreed with the RUC recommendations. Payment for the two phlebectomy codes (37765 & 37766) was adjusted for 2020 and dropped by about 31% effective January 1, 2020. The global period for both codes has also been reduced from 90 days to 10 days.

This payment drop was substantial, and while no AVLS member was pleased with this, a deeper question of working to ensure that patients had sustainable access to office-based phlebectomy care took center stage. To explore how the AVLS could support a better payment outcome, AVLS President Dr. Marlin Schul and Presidentelect Dr. Mark Meissner charged a member task force to conduct an in-depth analysis and recommend an advocacy strategy that might hold the promise of both more clinical granularity and improved payment. Drs. John Blebea and Ken Harper were asked to co-chair the new task force.

“At the beginning of the process, I was well aware that the challenge before us was both a clinical matter, but also had to be seen in the context of the rather complex coding and payment system that we have here in the United States,” noted Dr. Blebea.

WHERE ARE WE TODAY?

Early on, the task force’s work was energized by members who felt strongly that the deep cuts were a direct threat to patient care by potentially restricting access. The task force held several virtual calls in 2020. The task force members agree that the current coding paradigm based on the number of phlebectomy sites is unwieldy and does not lend itself to the clinical granularity required. However, the challenge is to develop a new framework that will hopefully more accurately reflect the clinical work involved, but this is by no means certain.

Defining a new coding paradigm is under active discussion, but the consensus is that a coding paradigm based on treatment zones will offer more granularity and describe the actual work better than the current “number of stabs” approach.

HARNESSING DATA & NEXT STEPS

In early 2021, Drs. Blebea and Harper began to coordinate with the AVLS PRO Registry Committee to see if there is data to inform our next steps. A registry research proposal has been developed to track cases and provide greater detail about patient characteristics and treatment zones. “We know that we cannot just rely on our own anecdotal opinion,” noted task force co-Chair Dr. Ken Harper. “Our strategy must have evidence behind it if we are to go forward and convince the national authorities that a new coding framework is required.” Any AVLS member who performs phlebectomy should work to get their data into the Registry platform. We will analyze the data submitted to the Registry and see if this can provide substantive direction going forward. In addition, work is underway to develop a mobile app for physicians to track phlebectomy procedures and report that data to the AVLS.

The task force’s work is a multi-year effort, but the task force is committed to getting the best outcome for AVLS members and patients.

TASK FORCE MEMBERS

John Blebea, MD, MBA, FACS

Ken Harper, MD, FACS, RPhS

James Albert, MD, RPVI, FAVLS

Marlin Schul, MD, MBA, RVT, FAVLS, DABLVM

Francis Lee, MD

Robert Merchant, MD, FACS, FAVLS

Mark Meissner, MD, FAVLS

Dan Monahan, MD, FACS

Stephen Daugherty, MD, FACS, FAVLS, RVT, RPhS

Chris Pittman, MD, FAVLS, FACR

Nick Morrison, MD, FACS, FAVLS, RPhS

Steve Elias, MD, FACS, FAVLS, DABVLM

Paul McNeil, MD

Michael Manning, MD

Duane Randall, MD

Satish Vayuvegula, MD, MS, FAVLS

Michael Graves, MD

Mark Iafrati, MD