In-Office Sialendoscopy: Transitioning from the OR to the Clinic

[Dr. Ashley Agan]:
Got you. Who is a good candidate to do it in the office? Because I'm sure you still do it in the OR a fair amount, depending on the patient. As you're moving patients to the office, who's the best person to do a sialendoscopy in the office?

[Dr. Wais Rahmati]:
Anyone who I'm concerned has an obstructive problem with their salivary gland. Then patients with small stones either found on imaging or where I have suspicion that they have a stone where you can't palpate it, but sometimes you may actually see it. You may see it, so I use a microscope in my office for every patient encounter.

[Dr. Ashley Agan]:
Rather than loops. Microscope instead of loops. Okay.

[Dr. Wais Rahmati]:
Correct. I have the microscope set up there. I immediately just do an oral cavity examination with the microscope and under high power magnification, sometimes you see these small 2, 3-millimeter stones that they're actually mobile. You can see them move in and out to the distal duct at the punctum. Someone like that, where you can see a small stone, or it just seems like it's very classic recurrent symptoms at mealtime, where it's probably a small floating stone that you can't palpate. That's a perfect setup for sialendoscopy. Then almost every patient who has at least a single gland, single parotid gland, who comes in with a story of recurrent swelling or even chronic pain or intermittent pain, these are all patients that I offer office-based sialendoscopy to.

I think that when someone comes in and they have multiglandular involvement and you're worried about an inflammatory autoimmune process, those are patients initially, I would say, are better in the operating room setting to evaluate. They can be quite tender as well due to the underlying inflammation in the glands, but even in my practice, as it's evolved, most of those patients get four-gland sialendoscopy in the office now, unless they're particularly tender or they're very concerned about pain.

[Dr. Ashley Agan]:
Got it.

[Dr. Wais Rahmati]:
I guess just to continue on in terms of patient selection, it's also about patient preference. I offer all my patients the option of local anesthesia, MAC, and general anesthesia with intubation. Whatever suits them. The majority actually prefer the idea of coming in alone and just having it under local anesthesia and maybe returning back to work. If anyone's concerned about the smallest amount of pain, if they're really anxious, if they have a history of recurrent syncope, those are the patients that I would probably reserve the operating room for.

[Dr. Ashley Agan]:
As we're rounding this out, I think we have to talk about where sialendoscopy is from a billing reimbursement standpoint and how you've been able to build this salivary gland center because you and I and patients all find this extremely valuable because it's minimally invasive, they're avoiding having their gland completely removed. With you doing it in the office, they're avoiding anesthesia, so I would imagine there is cost savings with that, but because sialendoscopy doesn't have a code, I think it has not been as widely adopted because it's like, how do we get this paid for? The scopes are expensive, they're delicate, they break. I think a lot of people can make a very good argument for why not to do it, so talk me through it. [chuckles]

[Dr. Wais Rahmati]:
Right. Everything you said, I completely agree with. That is probably one of the greater challenges in establishing a program. I think on my side, having the volume that I do justifies, moving forward with it. Certainly, for I think a lower volume practice, it is inherently challenging, as you said. We don't have a dedicated CPT code for this. The traditional salivary gland codes are, first of all, it doesn't represent what you're doing. If you're doing a diagnostic sialendoscopy, you can't use any of the other codes. Even according to the CMS rules, you can't. You have to use the 42699, the unlisted salivary code for it. Otherwise, you're not appropriately billing.

That being said if you did sialendoscopy with a sialolithotomy or a sialodochoplasty, the insurance companies will pay for the traditional codes, and they will again omit the sialendoscopy. What I've done, and there's a learning curve to this, where I initially started with the unlisted code, it wasn't paying, when I thought, "Okay, let's try a combination of the unlisted for the ones that are purely diagnostic and add the traditional codes," and realize that reimbursement is rather poor for this. For the last couple of years now, very consistently, I use 42699 code for almost everything, unless I'm not really doing it, like sialendoscopy is a secondary, just a quick look, and really, it's a large stone, it's right there. It'd be silly to not just do the sialolithotomy.

Everything else gets a 42699 code, and then the charges are based on the extent of surgery. If it's a diagnostic code, it's just we code it as 42699-01, and then everything incrementally goes up in terms of complexity.

[Dr. Ashley Agan]:
You've just created a fee schedule based on all of your expenses and how hard it is, and the time.

[Dr. Wais Rahmati]:
Correct. That's exactly what we've done, and we've stuck to it. In terms of reimbursement, the government payers, unfortunately, don't pay. It's essentially a write-off, but these are patients that need it. Again, I see them and I take care of them, not an issue. The commercial payers ultimately pay, but it requires persistency from your billers and coding team, multiple rounds of appeals. We send a package, I send a paper, a few papers that I've written, some justification and note, we send the patient's documentation and why this is being done, and the benefits to the insurance company, like cost savings.

There's a couple of really good articles that show that there's tremendous cost savings by doing it in the office. The payers pay and it's variable. Some payers pay within two months, and others, I think, I received some reimbursement after 18 months.

[Dr. Ashley Agan]:
Oh my gosh.

[Dr. Wais Rahmati]:
I'm happy to get paid 18 months later, but it's hard to plan your budget in some ways when there is so much in accounts receivable. I think here, the emphasis I want to make is, pick a way of doing this. I think the right way to do this is to do the 42699 code and just follow through with the appeals with the insurance companies and see it come through. Unfortunately, with Medicare and Medicaid, the reimbursement is not great. Now the managed Medicare and Medicaid programs will pay actually. There is a reasonable reimbursement through them.