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Reimbursement Particularly Atherectomy Appearsto be a Principal Driver for Intervention for Lower Extremity OcclusiveDisease, Particularly in Office-Based Labs
Dipankar Mukherjee, MD1, Brian Contos, BS2, Erica Emery, MS1, Homayoun Hashemi, MD1.
1Inova Fairfax Medical Campus, Falls Church, VA, USA, 2Advisory Board, Washington, DC, USA.

Objective(s): The purpose of this study was to examine the ongoing trend of migration of endovascular procedures being done for lower extremity occlusive disease from the hospital to office-based labs (OBL) since our previous analysis reported a year ago. We also analyzed the 12 month downstream utilization of repeat atherectomy following the incident procedure.
Methods: We analyzed fee-for-service Medicare claims data from 2011 to 2015. We examined the type of intervention (angioplasty, atherectomy, or stent), clinical setting (office-based lab [OBL], hospital outpatient [HO], and hospital inpatient [HI]) and operator specialty (vascular surgeon , cardiologist, interventional radiologist, and other). We also looked at repeat atherectomy procedures 12 months following the incident procedure.
Results: Consistent with our previous analyses, there was a continued growth in use of atherectomy in all infra-inguinal vascular beds. There was a 76% overall increase in atherectomy volume for Medicare beneficiaries between 2011 and 2015. In the same period, atherectomy increased by 380% in OBLs and by 30% in HO setting and decreased by 16% in HI setting. Across all settings of care, non-atherectomy peripheral vascular intervention (PVI) increased only by 2% between 2011 and 2015. During this time, case volume increased by 120% in OBLs and decreased by 12% in the HI setting, with no change in the HO setting. Atherectomy is the most common PVI in OBLs (representing 68% of cases) whereas stent placement is the most common PVI in HO setting (representing 37% of cases). Vascular surgeons and cardiologists continue to perform most of these interventions. There is a disproportionately high reimbursement for atherectomy procedures done in the office (Table 1).
Conclusions: Interventions for lower extremity occlusive diseases between 2011 and 2015 have migrated to the outpatient setting, predominantly to OBLs. Atherectomy use in OBLs continues to grow at a rapid rate and there is a high rate of repeat atherectomy within 12 months of the incident procedure.

Table 1: Medicare Reimbursement for Atherectomy by Clinical Setting in 2016
CPT CodeDescriptionPhysician OfficeHospital OutpatientPhysician Office as Percentage of Hospital Outpatient
37225Fem-pop atherectomy$10,723$9,542112%
37227Fem-pop stent + atherectomy$14,555$14,612100%
37229Tibial/peroneal atherectomy$10,483$14,61272%
37231Tibial/peroneal stent + atherectomy$12,976$14,61289%


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