Intravascular Lithotripsy for Fem-Pop Disease in the ASC

We begin by discussing Amanda’s role in the practice. She is an ex OR nurse and has been clinical director for their original hybrid ASC/OBL in Oklahoma City for 8 years. She has taken on many roles over the years, the most recent being COO. Some of her functions under this title include clinical revenue cycle management (RCM), payer negotiation, credentialing and accreditation. Since partnering with a private equity firm, she has also been collaborating with others in ASCs they have acquired around the country.

Dr. Melton states that intravascular lithotripsy (IVL) reimburses very well in the outpatient space, but that this is only true in the ambulatory surgery center (ASC) and does not translate to outpatient based labs (OBLs). Medicare pays for all associated Shockwave intravascular lithotripsy CPT codes, commercial insurance does not. They found in their practice that by using the Medicare fee schedule, they could prove to their local commercial insurance providers that it was worth paying for, and they are now getting it approved via both parties. Specifically, C9765, which is for IVL, percutaneous transluminal angioplasty (PTA) and stenting, pays $5000 more than the code that is just for PTA and stenting.

Lastly, we go over sizing and patient selection. In the ASC, he most commonly uses the 5.5, 6 and 7, which all go through a 5-6 Fr slender sheath in the foot. If you use an 8 then you’ll need a 7 Fr sheath, and if you use a size 9, 10, or 12, you’ll need an 8 Fr sheath. Dr. Melton emphasizes the importance of selecting the right patients for the ASC and hospital. In those with significant comorbidities or a femoral artery that will need a size 9, 10 or 12 balloon, he tends to do these in the hospital. He finds that he places a stent more often than not after IVL and PTA because of what he sees using intravascular ultrasound (IVUS). He shares a tip for using the current IVL balloon. Because it emits the strongest sonic pressure impulse at the center of the balloon, he uses IVUS to mark the most calcified segment, then targets this area with the center of the balloon. He remarks that the newer version, coming out soon, has a shorter balloon and emits the same strength across its entire length, allowing you to skip this step.