Otolaryngologists Increasingly Move Inferior Turbinate Surgery into the Office

There’s a new development in the surgical management of inferior turbinate hypertrophy (ITH), and, despite medicine’s fascination with the latest technology, it has nothing to do with lasers, radiofrequency ablation, microdebridement or any of the other new medical devices that have dominated the ITH literature.

Indeed, the “buzz” in ITH surgery these days has to do more with the location of surgery rather than with the surgical technique or equipment employed, said Timothy L. Smith, MD, chief of rhinology and sinus-skull base surgery at the Oregon Health and Science University in Portland, and a member of the ENTtoday editorial advisory board.

Specifically, increasing numbers of rhinologists and other otolaryngologists are electing to perform ITH surgery in the office rather than the hospital, and the primary driver of this trend is economic. In uncomplicated cases, where hypertrophy, rather than serious underlying pathology, is the major cause of nasal congestion, “why incur the added costs and hassle of hospitalization?” Dr. Smith said. “Especially in this era of increasing cost containment, I don’t think insurers are going to continue to pay for those added expenses.”

Michael Setzen, MD, the immediate past president of the American Rhinologic Society and practice management coordinator of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), is a major proponent of this move to office-based ITH surgery. Dr. Setzen said he has been performing the procedure out of the office for at least a decade, but added that the benefits of such an approach aren’t just economic. Many of the gains, he said, are on the patient side of the equation. “In my office, I can keep them comfortable; it’s much easier to schedule a time for surgery and keep to that schedule; and, perhaps most importantly, in the types of uncomplicated cases we’re really taking about, I can use just a local anesthetic. So they stay alert and awake and go home in great shape.”

That’s not to say, however, that financial considerations are not an important determinant of making a successful switch to office-based ITH surgery, Dr. Setzen stressed. Without a good understanding of the start-up costs involved and the key ways in which in-office vs. hospital-based reimbursement differ, he pointed out, the transition could be a rocky one.

Start-Up Costs

First, the up-front costs should be considered. Those costs will vary based on whether you have an existing sinus surgery practice or are setting up a new office practice. “If you’re just starting out, you will need to purchase endoscopes, which is the building block of doing any sinus surgery, and then you’ll also need video equipment to photograph and record your cases,” Dr. Setzen said. “This is very important for documenting medical need, for getting adequate reimbursement, for liability, etc.” The price tag for that initial investment “is about $50,000, although that of course can vary depending on the size and scope of your practice,” he said.

The next consideration in calculating start-up costs is to determine which of the newer methods for performing ITH surgery you’ll be using. Two methods have gained traction in recent years and are used by most practitioners to reduce the soft tissue and underlying structures of enlarged turbinates and ease chronic congestion: radiofrequency ablation (RFA) and microdebridement. Both methods employ a power-source unit that must be purchased by the office-based practitioner in addition to disposable handpieces that attach to the power sources and can only be used for a single patient before being discarded.

Dr. Setzen said RFA or debridement units won’t add much to the cost of equipping an office for ITH surgery because many manufacturers will sell the units at a heavily discounted rate or even give them to an office at no charge. But they do charge for disposable handpieces. At about $100 per unit, those costs can quickly add up, he said. That’s why a firm understanding of how reimbursement works is so important in these endeavors. In a hospital, Dr. Setzen said, the surgeon and hospital are reimbursed not only for the ITH procedure, but also for the handpieces and other medical supplies used during the surgery. In the office setting, however, only the surgery itself is paid for. “We cannot bill for supplies or these handpieces, because payers have determined that all of those costs are built into the relative value of that office-based procedure,” he said. Moreover, the physician has to absorb those unreimbursed costs; they cannot be transferred to the patient via follow-up billing, he added.

Given these factors, is it really cost-effective for otolaryngologists to bring ITH surgery in-house? “It may take a few years to recoup your initial investment,” Dr. Setzen said. “But for me, the added convenience to the patient and the practice is well worth it.”

Other than cost, another reason some sinus surgeons balk at performing office-based surgery is the difficulty of untangling the sometimes arcane coding methods that payers require in order for the practice to get reimbursed the correct amount for a given procedure. “At first glance, it can be intimidating,” Dr. Setzen said. But by keeping a few key coding concepts in mind, most practices can steer clear of trouble, he said (see “Inferior Turbinate Surgery Coding Tips,” p. 9).

Patients Also Benefit

Peter Hwang, MD, professor of otolaryngology-head and neck surgery and chief of rhinology at the Stanford University Medical Center in California, is another proponent of office-based ITH surgery and has been teaching an AAO-HNS course on the procedure for more than a decade. He agreed with Dr. Setzen’s summary of the main benefits of the outpatient approach, including avoidance of general anesthesia, faster patient recovery and easier scheduling. He also stressed that there are major cost savings that will accrue to the patient as well. “Total charges to the patient will be significantly less, because nursing and anesthesia charges are avoided,” he said. Depending on a patient’s insurance coverage and deductibles, such charges can quickly add up, he added.

Dr. Hwang said that in his own practice, he has not encountered any reimbursement or coding challenges that were not insurmountable, provided a few basic tenets were followed. “It’s crucial that you carefully document physical examination findings of turbinate hypertrophy to establish medical need,” he said. It’s also important, he added, to document that the patient has failed an adequate course of medical therapy before surgery is considered; otherwise, payers may balk at reimbursing for the procedure.

Another important consideration in making the transition to office-based ITH is to have a firm grasp on which of the many methods of reducing the turbinates can be done safely and effectively in the outpatient setting, Dr. Hwang said. “While many options have been shown to be efficacious, each method has its own equipment requirements and technical concerns that should be considered carefully by the surgeon,” he said. Dr. Hwang added that he prefers microdebridement, citing published evidence of excellent long-term outcomes with this technique (Laryngoscope. 2006;116:729-734, and 2009;119:414-418). But he does not perform a related procedure, turbinate outfracture, in office-based settings. “I am more comfortable doing that in the hospital, where the patient is [under anesthesia],” he said.

Dr. Setzen said he does not have a problem doing outfracture in the office, but added that there are more important considerations when deciding on a strategy for performing office-based ITH surgery. For example, there are safety factors to consider when making the outpatient transition, such as having the appropriate emergency equipment on hand. “You have to be prepared in the unlikely event that a complication occurs, such as a serious bleed or an airway obstruction,” Dr. Setzen said. “Remember, in most cases we don’t have an anesthesiologist or other physician helping us, so you need to be ready to resuscitate a patient or perform some other emergency intervention.”

Drug-related adverse events are another risk physicians need to be prepared to face, Dr. Setzen noted. “When we operate on the nose, we generally inject a local anesthetic with epinephrine, which can cause tachycardia and other arrhythmias. So you need to be sure that the patient is medically in good enough shape to tolerate the procedure, because the last thing you want is for a cardiopulmonary event to take place in the office.”