F Hampton Roy, M.D.
Ophthalmic Outpatient Surgical Society (OOSS) Councilor to AAO
“Vitreoretinal surgeons have traditionally operated in hospital-based settings for several reasons. Until recently, most procedures were long and tedious, they often required the use of multiple, complex instrumentation, and general anesthesia was the norm. So it is not hard to understand why most surgeons chose to operate at the hospital.” 1
Over the last few years vitreoretinal surgery has changed dramatically. Topical and subtenon anesthesia is now being used. The instrumentation is simpler, and more efficient to use and therefore more retinovitreal surgeons are considering and have moved part of their surgery to ASCs.
There are several advantages to working in an ASC rather than a hospital. One advantage is that in a smaller environment there is less turnover in personnel. The surgeon can work with the same people that know the routine for each procedure. Secondly, having a nearby operating room with trained staff provides the surgeon greater efficiency and a faster turnaround time. The patient benefits with a quicker, more efficient surgery, with a decrease in the possibility of intraoperative complications. The postoperative complications are reduced with a more rapid recovery time. Efficiency in the operating room can provide the opportunity for more productivity in the office and therefore improved patient care. Thirdly, in an ASC patients frequently feel a warm comfortable environment that can not be achieved in a hospital setting.
There are several disadvantages of working in an ASC. It is more difficult to provide the instrumentation for long complicated cases that require special equipment and supplies and longer anesthesia time.
Experts in vitreoretinal surgery have suggested the following cases are suitable for the ASC.2,3,4,5 The best candidates for routine ASC cases are the 25 gauge vitrectomy surgeries. This includes macular disease (epiretinal membrane, macular hole, macular edema) and non-clearing vitreous hemorrhage. Other suitable cases include straight-forward diabetic retinopathy cases and some primary scleral buckle procedures. In general, elective cases that are done during regular hours are good procedures to be performed at ASCs. Cases that can not be handle in an ASC setting include procedures that involve intraocular gases, silicone oils or perfluoron, diabetic traction retinal detachments and other emergencies.
Some of the instruments needed for vitroretinal cases in the ASC include:
A vitrector with a light source. The vitrector allows the removal of the vitreous gel through a very small incisions. The device includes a miniature, hand-held cutting device and a high-intensity fiberoptic light source needed to illuminate the eye while the surgeon works. A vitrector can be purchased as a stand-alone unit for about $60,000 or add a vitrector module to your phacoemulsifier for about $15,000.
An Argon laser with an endolaser attachment. The Argon laser, used to treat retinal tears and proliferative diabetic laser probe that is used for photocoagulation. A refurbished model costs about $30,000.
A cryotherapy unit. This device is used to reattach retinal tissue to the eye wall in the case of retina tears or defects. The cryotherapy unit freezes the tissue, in effect “tacking” it back to the supporting structures.
Various hand instruments. These include scissors, forceps, picks and the like. The cost of a set of retinal instruments vary from $5,000 to $15,000, depending on the surgeon preference.
Supplies. Depending on the procedure to be performed, a typical retinal surgery pack includes items such as drapes, cautery supplies, a laser probe, sutures, disposable covers for the scopes and any necessary medications. Efficient surgeons get their pack costs to below $200 for a simple procedure like a retinal detachment. For complex vitrectomy cases that require an endolaser, procedure packs can be about $500.
Operation Microscope. Usually the microscope available for anterior segment surgery is adequate. 6,7
Reinbursement to ASC is different from hospitals. For example there is no reimbursement for intraocular gases, silicone or perfluoron. There is several high-volume vitreoretinal procedures with high reimbursement discrepancy rates. These include:8
Code Description OPD Rate ASC Rate Difference
67010 Vitrectomy (eye) $1,967.49 $630.00 $1,337.49
67015 Vitreous aspiration $ 1,967.49 $333.00 $ 1,634.49
67038 Mechanical vitrectomy $1,967.49 $630.00 $ 1,337.49
67107 Retina repair with scleral buckle $ 2,275.29 $717.00 $ 1,558.29
One question asked is about retinal surgery profitability in the ASC.9 Average 2005 reinbursements minus facility and staff costs provides this data.
Retina Surgery Economics
Average 2005 reimbursements* minus facility and staff costs.
*CPT 67036 Pars Plana Vitrectomy
*CPT 67038 Vitrectomy with Epiretinal Membrane Strip
*CPT 67039 Vitrectomy with Focal Endolaser
*CPT 67107 Repair RD with Scleral Buckle
*CPT 67108 Repair RD with Buckle and Vitrectomy
*Reimbursement figures represent average national rate, may vary by region.
There is a regional difference where vitreoretinal cases are performed. Arizona is a leader in vitreoretinal procedures performed in the ambulatory surgery center setting.
There is a growing trend for some vitreoretinal surgery to be performed in an ambulatory surgery center. These cases include macular diseases such as epiretinal membrane, macular hole, and macular edema. Other suitable cases include non-clearing diabetic hemorrhage, primary scleral buckling, and straight-forward diabetic retinopathy cases. Although there is a regional variation, the nationwide trend of more vitreoretinal surgery should continue.
Kadrmas, E.F.: About Time? Vitreoretinal surgery in the ASC: How progressive Doctors and Facilities are making it work. Ophthal. Management, March 2001.
Charles, S: Personal communication. May, 2005
Capone, Jr, A: Personal communication. May, 2005
Friedman, S: Personal communication. May, 2005
Mieler, W.F.: Personal communication. May, 2005
Lee, J.: How to expand your eye services. Outpatient Surgery. May, 2002.
Neu, III, L.T.: How we added retina to our ASC. Outpatient Surgery. August, 2003
Stegman, M.S.: Hospital outpatient surgery versus ASC casts and reimbursement. J. Healthcare Compliance. March-April, 2005
Sheppard, S.C.: How to make retina work for you. Outpatient Surgery. August, 2002