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Inpatient biopsies for cancer work ups when patient is admitted for something else
Are you guys doing these pretty routinely?
We try and do recommend they be done outpatient when patient is in better health and after appropriate work up (e.g. pet ct to look better biopsy sites).
We usually get push back from IM docs claiming it needs to be done inpatient. Patient may be lost to follow-up otherwise. Which i always say, do you plan on doing chemo , radiation, and surgery during this admission so they are not lost to follow-up?
Its my understand that hospital isnt paid for these if it does not affect inpatient management.
How do you respond to these requests?
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45 Replies
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I do them.
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Quote from drad123
I do them.
Part of the reason for your suffering. You should be saying no.
This is one more thing hospitals are going need to subsidize if they expect radiologists to continue doing them and not get paid appropriately, or at all.-
Quote from Thread Enhancer
Quote from drad123
I do them.
Part of the reason for your suffering. You should be saying no.
This is one more thing hospitals are going need to subsidize if they expect radiologists to continue doing them and not get paid appropriately, or at all.
DRG hospital payment has nothing to do with physician billing. I’m surprised you don’t know that.
-Besides, I am paid by wrvu, not collections.-
I do them. I try my best daily to do what is best for the patient. So many outside forces have invaded the practice of medicine and it is enough to mentally upset any good physician – but I feel as long as I keep doing right by the patient first and foremost in my mind and behavior, I still find my career fulfilling.
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I do unless there’s a question of survivability. Like sure the vented post crani for malignant edema after ica occlusion isn’t going to move much if I come up to the icu and do their parotid mass bedside, but I’d rather see them make it to/through rehab.
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If the patient is likely to be in the hospital for awhile (placement, pneumonia that wont resolve, etc) it seems reasonable. Waiting till discharge will be a delay in care. Also if they go to SNF after inpatient it can be difficult for them to get to outpatient appointments from SNF. Requires transport and all sorts of paperwork for SNF staff. Any of these scenarios justify doing it inpatient.
If they are going to be discharged in a few days, even putting aside the money aspect, just why? I don’t buy the argument of lost to follow up risk. They will have to show up to 40 appointments at least to get their chemotherapy infusions, surgical eval, radiation treatments, etc. If they can’t show up to one will they really follow through with treatment? -
Quote from Waduh Dong
I do them. I try my best daily to do what is best for the patient. So many outside forces have invaded the practice of medicine and it is enough to mentally upset any good physician – but I feel as long as I keep doing right by the patient first and foremost in my mind and behavior, I still find my career fulfilling.
Now that I can get behind. Do it because it’s the right thing to do for the patient.
Does not change the fact that if these are being pushed for by a hospital system and they do not pay enough to warrant the inefficient time use of most hospital departments, it’s the hospital that should make the radiologists whole.
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Quote from drad123
Quote from Thread Enhancer
Quote from drad123
I do them.
Part of the reason for your suffering. You should be saying no.
This is one more thing hospitals are going need to subsidize if they expect radiologists to continue doing them and not get paid appropriately, or at all.
DRG hospital payment has nothing to do with physician billing. I’m surprised you don’t know that.
-Besides, I am paid by wrvu, not collections.
This is very true and not everyone understands this. As a regular PP radiologist who is billing on their own, it doesn’t matter. We used to fight these more, now less so. Still don’t love it. I like everyone to have an outpatient time slot-
Super annoying but we do a lot of them.
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Still say no to most unless I think it will make a huge difference. Occasionally acute lymphoma or possibly if early dx might lead to sooner treatment and better outcome. 90 homer with diffuse Mets can go home and kick the bucket
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Quote from TurboEcho
This is very true and not everyone understands this. As a regular PP radiologist who is billing on their own,[b] it doesn’t matter.[/b] We used to fight these more, now less so. Still don’t love it. I like everyone to have an outpatient time slot
We understand it. However, it does matter. The amount we are paid by insurance or CMS does not come close to covering the inefficient use of our time in the hospital. Having to do these makes us need to staff more people not working at capacity but being paid a full salary, rather than one at capacity and able to shunt the unnecessary procedures to the outpatient setting. I’m surprised how few people working in PP understand that.-
Quote from Thread Enhancer
Quote from TurboEcho
This is very true and not everyone understands this. As a regular PP radiologist who is billing on their own,[b] it doesn’t matter.[/b] We used to fight these more, now less so. Still don’t love it. I like everyone to have an outpatient time slot
We understand it. However, it does matter. The amount we are paid by insurance or CMS does not come close to covering the inefficient use of our time in the hospital. Having to do these makes us need to staff more people not working at capacity but being paid a full salary, rather than one at capacity and able to shunt the unnecessary procedures to the outpatient setting. I’m surprised how few people working in PP understand that.
cool story
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Story?
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Im always amazed in medicine how people are willing to create a big inconvenience for others in order to save themselves a small inconvenience.
Particularly if a qualified radiologist is already in the hospital its so much less work for the patient and the system just to do the bx while still in-house. (No pre-auth, no travel for patient, no separate registration, no use of special recovery room resources, labs can be obtained well ahead of time, etc.)-
Quote from PVIR
Particularly if a qualified radiologist is already in the hospital its so much less work for the patient and the system just to do the bx while still in-house. (No pre-auth, no travel for patient, no separate registration, no use of special recovery room resources, labs can be obtained well ahead of time, etc.)
The one who eats it is the hospital. As an OP procedure, they could collect technical charges. If it’s done during a unrelated IP stay the TC is included in the DRG. If they decided that they don’t want to eat that cost, it wouldn’t happen, but they are the ones pushing for it. The potential loss in profit if a percentage of new cancer patients leaks to the competition or is lost to follow-up pays for many biopsies. Running the IR department is a sunk cost, the incremental cost from ‘one additional inpatient biopsy’ is minor. The argument against it is that occasionally it may add to LOS.
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Maybe “liquid biopsies” will replace tissue biopsies some day …
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Im amazed how few people here understand the true cost of running an inpatient IR practice. Incremental is great until the one more means hiring another FTE. Its very hard to be properly staffed when a group cant control efficiency. As a result the group is typically understaffed in which case the extra procedure contributes to the burnout that is so prevalent; or overstaffed, in which case the extra procedure is welcomed but others in the group are subsidizing their salary.
The best way to manage this is to have an over staffed IR team contribute to the DR work. Otherwise the hospital should subsidize the practice to have them available.
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Quote from Thread Enhancer
Im amazed how few people here understand the true cost of running an inpatient IR practice. Incremental is great until the one more means hiring another FTE. Its very hard to be properly staffed when a group cant control efficiency. As a result the group is typically understaffed in which case the extra procedure contributes to the burnout that is so prevalent; or overstaffed, in which case the extra procedure is welcomed but others in the group are subsidizing their salary.
The best way to manage this is to have an over staffed IR team contribute to the DR work. Otherwise the hospital should subsidize the practice to have them available.
Biopsies can be done by any board certified radiologist. Like MR or CT or x ray. Basic skill.
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Yes. You beat me to it. Thats solution A of the over staffed problem.
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Quote from Thread Enhancer
Yes. You beat me to it. Thats solution A of the over staffed problem.
Now paying a dedicated IR to do inpatient biopsies and taking it out of my reading fees which goes on in many practices- no.
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Quote from drad123
Quote from Thread Enhancer
Yes. You beat me to it. Thats solution A of the over staffed problem.
Now paying a dedicated IR to do inpatient biopsies and taking it out of my reading fees which goes on in many practices- no.
Yes, you get it.
It goes on if a group is beholden to a contract that is not subsidized by the hospital to be overstaffed and add on these “incremental” exams with ease. You said before that you get paid by wRVU to do these. You getting what you deserve? If not there is a skim somewhere. Either at the group or hospital level. -
When it’s my turn, I’ll want my cancer diagnosed ASAP to get therapy going. Just do the biopsy.
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Forgive a dumb question – for unnecessary inpatient diagnostic procedures (eg thyroid us to characterize a nodule seen on a chest ct for a patient admitted for pneumonia) I understand the hospital cant collect the technical fee because the patient is admitted under a pneumonia drg. But are the professional fees for me any different than if this patient was imaged next week at the hospital owned outpatient imaging center?
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I’m just glad we haven’t reached the point ( YET ) where the F^^^ing ER doc is ordering them. I’ve had my fill of stat total body CT to evaluate metastatic disease for the ER doc.
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Five issues:
1. DRG — many of the people who posted here seem to have no idea what this is. Please read up on it.
2. On the patient care side — any single minute/hour that a patient stays in the hospital, the risk of all kinds of comorbities/mortality increase. Think DVT, PE, infectious disease issues such as MRSA, muscle atrophy, cardiopulmonary reserve loss, etc. etc.
3. Cancer care is a two way street — if patient is noncompliant in even getting diagnosed, do you really think they will suddenly become boy scouts and be compliant on all the follow-up visits, chemo, ancillary procedures, ad nauseam?
4. The docs that push this kind of nonsense are typically hospitalists who have zero idea how the outpatient clinic/oncology world works.
5. You just made a 200-500 procedure into a 5000-10000 dollar procedure (of course 95% of it going to the hospital with high chance the IR doc is not collecting anything). -
Quote from PirateRad
Five issues:
1. DRG — many of the people who posted here seem to have no idea what this is. Please read up on it.
2. On the patient care side — any single minute/hour that a patient stays in the hospital, the risk of all kinds of comorbities/mortality increase. Think DVT, PE, infectious disease issues such as MRSA, muscle atrophy, cardiopulmonary reserve loss, etc. etc.
3. Cancer care is a two way street — if patient is noncompliant in even getting diagnosed, do you really think they will suddenly become boy scouts and be compliant on all the follow-up visits, chemo, ancillary procedures, ad nauseam?
4. The docs that push this kind of nonsense are typically hospitalists who have zero idea how the outpatient clinic/oncology world works.
5. You just made a 200-500 procedure into a 5000-10000 dollar procedure (of course 95% of it going to the hospital with high chance the IR doc is not collecting anything).
I will admit I am not educated with respect to DRG/in-pt payment. I often wonder if I am actually getting paid anything for the 30th CXR or whatever for these in-pts are getting.
I get both sides of the argument but if its all about the patients and their needs, why aren’t we routinely performing in-pt PET/CTs, DEXA’s, breast imaging, MSK MR/arthrograms etc, and thyroid US’s (though I have started to notice these more lately) -
It’s the oncologists who are asking for this.
We get paid for it, just like we get paid for an abscess drain or a dialysis catheter on an inpatient.
If the hospital was losing any substantial amount of money on it, they would tell us not to do it. If it increases LOS, that’s not my problem.
Most of them can be done by one of the interventional PAs.
They are occasional requests, not a substantial impact on interventional procedure load. For the IR department they are actually less of a resource suck than doing them as OP. They come from the floor, they go back to the floor. Pre and post sedation issues, anticoagulation everything can be managed during inpatient rounds by the PA or farmed out to the hospitalists. -
Inpatient biopsy requested.
You say no, for whatever reason.
Patient is lost to follow up, but probably would have cared more if they had an actual cancer diagnosis.
Patient dies early but could have had some quality of life years to say goodbye if they were treated early.
You have to live with yourself
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Just say no. Very few cases that an inpt bx is warranted. For example:bone marrow biopsies for acute leukemia (which should be done at the bedside, but has been going to radiology more and more these days). Most cancers can wait a couple days.
Inpt PET scans should not be performed either.
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PAs and NPs are very helpful in my practice. We however dont have them do biopsies other than bone marrow biopsies. They also do vascular access/para/thora/diagnostic venograms.
Lung/solid organ biopsies are the highest risk procedures we do. Much higher than angioplasty/EVAR/embolization.
I am curious the type of procedures others allow their midlevels to do.
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Quote from fw
It’s the oncologists who are asking for this.
[b]We get paid for it, just like we get paid for an abscess drain or a dialysis catheter on an inpatient. [/b]
If the hospital was losing any substantial amount of money on it, they would tell us not to do it. If it increases LOS, that’s not my problem.
Most of them can be done by one of the interventional PAs.
They are occasional requests, not a substantial impact on interventional procedure load. For the IR department they are actually less of a resource suck than doing them as OP. They come from the floor, they go back to the floor. Pre and post sedation issues, anticoagulation everything can be managed during inpatient rounds by the PA or farmed out to the hospitalists.
So we do get paid our pro-fee for in-pts? I’m hoping we do, a lot of time consuming cases (full spine MR with and without for mets etc)
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We have to learn to say “No” in life. It is a great skill to have. Most people esp radiologists have a hard time saying no. They feel disagreeing is not what nice people do.
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Interesting how the discussion with respect to getting paid the professional fee goes back and forth. On that specific topic (I am not addressing the moral/ethical high ground card at all) think about this. If the type of patient we are focusing on is typically the one “will get lost to follow-up” — how many of those you think are insured at all?
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Quote from PirateRad
Interesting how the discussion with respect to getting paid the professional fee goes back and forth. On that specific topic (I am not addressing the moral/ethical high ground card at all) think about this. If the type of patient we are focusing on is typically the one “will get lost to follow-up” — how many of those you think are insured at all?
Cancer population is mostly medicare age, so I would say we get paid for most.
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I’m not sure it is as much of a “lost to care” as it is that health systems want to lock-in the patients by getting the process rolling. At least in our health care system, I hear the concern is that they leave the system without the process being started and go somewhere else to get the workup and then they lose the patient.
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So the system needs to pay radiology a premium for keeping the patient in the system .
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Quote from CU88
I’m not sure it is as much of a “lost to care” as it is that health systems want to lock-in the patients by getting the process rolling. At least in our health care system, I hear the concern is that they leave the system without the process being started and go somewhere else to get the workup and then they lose the patient.
Yep. This.
They go to their PCP who sends them to ‘his’ oncologist, they may go to the competition to get their care. That would be a tragedy.
Occasionally it can make sense to even biopsy a breast lesion while a patient is in the hospital. I remember one case from tumor board where a late 30s patient was in the hospital for an acute gallbladder but was noticed to have enlarged axillary nodes. An astute internist actually palpated a breast lesion which was documented to be a suspicious mass on US. Patient went home. Between the difficulty to get an appointment with the noctor PCP and the notoriously cheap health insurance Co dragging their feet, the workup for this lesion dragged on for many weeks before it was finally diagnosed. I have gotten a lot less sanctimonious on this issue. These incidentally detected breast masses are never small or subtle things but rather big eggs that are a 10min biopsy.
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This is such a pain in the butt issue in my group right now. The whole thing is a mess for like 10 intersecting issues. We have no clear guidance from administration as to whether they want us to do these procedures, other than the occasional comment of hospital doesnt get paid. Add on top of this we are short CT techs and between urgent drains and outpatients, we have a hard time scheduling in patient biopsies. Add on top of that working at a teaching institution where every intern thinks it is their responsibility to work up every incidental cancer even if a patient is so sick, a complication could push them over the edge. I think the hardest part of all of this is trying to triage which patients get room time. The clinicians are no help because to them every request they place is the most important thing in the world.
I think the bottom line is, if there is open room time, and the patient is an appropriate candidate for the procedure, I schedule them and get it done. If patients can be discharged and scheduled as an outpatient I suggest this, but if I can do it, I do it.
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This is definitely practice setting specific. Something that makes sense in a well resourced community hospital may not make sense in a resource constrained tertiary care center. In our case, it’s not the intern or hospitalist noctor who is pushing for this. It’s usually a request from a oncologist who we have worked with for years or decades. If they have seen the consult and find that the patient would benefit from an inpatient biopsy, it’s hard to argue against it on purely economic grounds.
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As the Polish say, nie mój cyrk, nie moje małpy,
but reading this and the [link=https://www.auntminnie.com/forum/tm.aspx?m=735415]imaging use rises in emergency department[/link] thread, the money seems to be excessively distorting priorities.
Some seem happy to accept inappropriate referrals from unqualified ER staff for the $, and defer biopsies until they pay more $.
At some level, we all work to get paid, but something is rotten here.
(I get paid by the hour, no-one is counting my RVUs, and NHS radiology is a disaster, so who am I to comment!)
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Quote from drad123
Quote from Thread Enhancer
Quote from drad123
I do them.
Part of the reason for your suffering. You should be saying no.
This is one more thing hospitals are going need to subsidize if they expect radiologists to continue doing them and not get paid appropriately, or at all.
DRG hospital payment has nothing to do with physician billing. I’m surprised you don’t know that.
-Besides, I am paid by wrvu, not collections.
Of course I know that. Not what I am talking about. If you are paid by wRVU, who is paying you?-
Quote from Thread Enhancer
Quote from drad123
Quote from Thread Enhancer
Quote from drad123
I do them.
Part of the reason for your suffering. You should be saying no.
This is one more thing hospitals are going need to subsidize if they expect radiologists to continue doing them and not get paid appropriately, or at all.
DRG hospital payment has nothing to do with physician billing. I’m surprised you don’t know that.
-Besides, I am paid by wrvu, not collections.Of course I know that. Not what I am talking about. If you are paid by wRVU, who is paying you?
Hospital. I suspect hospital may not be getting paid but don’t want the patient to go somewhere else once outpatient as another poster has said above. Another possibility is inpatient biopsy dollars too small to show up on hospital admin radar.
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Makes sense for the hospital. Get them diagnosed and into the cancer industrial complex.
‘Few things in medicine rival the tragedy of a new presentation cancer walking out of your hospital and into the competitors cancer center.’
Medically there is of course little reason to do that. The argument locally is that often patients have tenuous access to primary care. You send them home from the hospital they often get lost to follow up or have 4-6 week delays until they get diagnosed. I you biopsy them in the hospital, you can plug them right into the cancer center intake.
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Quote from hopefulradsfuture
How do you respond to these requests?
‘Order a CT CAP with contrast , put in a consult request. Cindy our PA is going to be up this afternoon to tee up the biopsy for tomorrow.’
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Try not to do as inpatient, no one gets paid, but depends on circumstances. Get case manager involved so they are hooked up with Cancer Ctr. We often do them day after discharge. A call to oncologist saying were scheduling this bx, its going to be malignant, can you see them in x days, after path is back?
On a side note, what number is x for youse? Ours used to be 2 usually, now 8-10.
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