Before otolaryngologists embraced image-guided surgery systems as the most efficient and safest way to perform endoscopic sinus surgery, it looked as if these devices weren't cut out for today's ORs. Image-guidance use added 15 to 30 minutes to OR time and $500 to case costs compared to traditional endoscopic technique, according to a 1999 study by Ralph Metson, MD, at the Massachusetts Eye and Ear Infirmary. This is hardly the case you want to make to invest in a six-figure system. So how is it that image-guided navigation is rapidly becoming the gold standard for endoscopic sinus surgery?

• It's proving to be highly accurate. Studies have demonstrated the ability of image-guidance systems to provide anatomic localization to within 2mm of accuracy during routine clinical use. This can lower revision rates and complication rates.
• It's a draw for surgeons (especially newly trained) and patients. "For centers wanting to do lots of sinus surgery, market share will depend on you having the device," says otolaryngologist Richard Lipton, MD, of Danbury, Conn. "For a lot of the sinus work being done, if you don't have the device, you're not going to grab the case."
• It doesn't have to eat up precious OR time. A navigation system's initialization, registration and set-up must be fast, reproducible and generate a very high level of accuracy at the onset of the surgical procedure, says otolaryngologist Jay Klarsfeld, MD, Dr. Lipton's business partner. Equally important is the system's ability to maintain that accuracy throughout the entirety of the case. "Every time your surgeon must re-register the patient, the case time lengthens and affects the center's bottom line," he says.
• It's billable (sometimes). You can bill for using image guidance using CPT code 61795, Stereotactic Computer-Assisted Surgical Navigation. Payment varies by geographic region and depends on the insurance carrier, says Dr. Lipton. Unlike HOPDs, ASCs can't bill Medicare a technical facility fee for the use of CPT Code 61795, which can be used only when the imaging device is used to guide intracranial, extracranial or spinal surgery. Keep in mind that this is an add-on code that is billed in addition to the CPT codes you'd normally list for the procedure. Medicare should pay a professional (surgeon's) fee when billing 61795 no matter where the procedure is performed. The Medicare facility fee restriction doesn't necessarily apply to other payers.
• It doesn't have to bust your budget. Purchase price aside, judge each system by disposable costs per case. For ENT imaging, disposable costs per case can run anywhere from less than $20 to more than $300. Some systems require single-use navigational hardware or tools costing $60 to $250 per case, while others limit these costs to about $20 per case, says Dr. Klarsfeld.
• It doesn't take many cases to make it work. A conservative figure of $300 paid per use and a three-year amortization of the expense would require about 10 uses per month or just more than twice a week for the machine to pay for itself, says Dr. Lipton. "As long as you're doing a handful of cases a week, the machine will likely pay for itself," he adds. "If you're doing a modest amount of case volume - more than five per week - then the purchase is a no-brainer, particularly if you take into account incremental case volume as a result of its availability."