Urologist Henry Rosevear, MD, turns his focus to the topic of evolving approaches to treating stones—and how urologists are compensated for these procedures.
Henry Rosevear, MD
I was not a urologist when the first ESWL machine was introduced; but I can imagine the debate that must have raged about how best to use that technology. I was also not around when the first ureteroscopic laser lithotripsy (URS) procedures were introduced (please insert your own comments here about my age and lack of experience), so while the literature does show the academic debate between ESWL and URS—a debate that continues to this day, I might add—I did not get to experience the more visceral part of that debate.
I am here, however, for the introduction of truly high-powered lasers and their application to stone disease. And I argue that this new technology is changing and should change not only our algorithms for treating stones but also how we are compensated.
Recently, a 60-something-year-old female presented to my ER with fever, flank pain, and a UTI. CT showed bilateral 3-cm renal stones with mild enlargement of the renal pelvis’s
bilaterally. I placed bilateral stents and treated her infection. When I saw her in clinic a week later to discuss her stones, even though the guidelines (and yes, I’m well aware that the AUA’s guidelines on the surgical management of kidney stones specifically address this patient [statement 22 in this case]), while the patient and I discussed PCNL, I did not strongly suggest that procedure. Rather, I recommended bilateral ureteroscopy. And 90 minutes later, thanks to an incredibly powerful laser that allowed me to use settings of .6 and 60, and a sheath to allow my dust to wash away, the patient was stone free.
That is not something that was possible just 5 years ago. Imagine treating bilateral 3-cm stones with settings of “6 and 6.” No thank you.
Now, before anyone becomes defensive and accuses me of saying that ESWL should go away (I’m not, though there is an interesting argument well summarized in this meta-analysis showing modern URS to be superior in cost and efficacy), what I would like to discuss is how ureteroscopy with a high-powered laser has become a viable option for stones previously best treated with PCNL and how the wRVUs for PCNL and/or ureteroscopy needs to be readdressed.
I think most urologists would agree that from a physician’s standpoint, the work involved in treating a <1-cm renal pelvis stone is approximately equal between ESWL and ureteroscopy. Both take well less than an hour and are simple outpatient procedures. And the wRVUs for those procedures reflect that, with URS (52356) being worth 8 wRVU and ESWL (50590) being worth 9.77. You can argue the details of those values, but they are approximately equal. We all know that the profit margin for the 2 cases depending on who owns the ESWL machine is radically different, but that is a different discussion. What bothers me is the wRVU assigned to a PCNL for a stone >2 cm. Any guesses? 23.5.
Three times the work for a ureteroscopy? Maybe that used to be correct in the past, but as any urologist who has access to one of these new high-powered lasers knows, that is not true now. Something has to give.
And it is also not fair on the facility either. These new lasers are expensive, with some being more than $150,000, and the facility needs to be correctly reimbursed for their capital outlay also. Remember, the historical high cost of the ESWL machine is why the facility fee for ESWL is so high.
To those smart people on the guideline committees, it may be time to re-work your suggestions on how to treat stones in the 2-cm to 4-cm range, as your guidelines may have become overcome by new technology.
And to those hard-working people who decide on how CMS values our work, I’d recommend the following changes that seem to more appropriately compensate both the facility and the surgeon for their capital and their work given the recent technological improvements:
• 52356, stones <2 cm: 8 wRVU
• 52356, stones >2 cm: 12 wRVU
• 50080: delete
• 50081, stones <4 cm: 16 wRVU
• 50082, stones >4 cm: 24 wRVU
Just one small-town plumber’s opinion.