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Is Your Facility Ready for Lap Cholecystectomies?
Experts offer advice on what you need to get started with this procedure and make it efficient.
Nathan Hall
Publish Date: January 18, 2008   |  Tags:   General Surgery

Medicare's new ASC payment system will cut the reimbursement rates for many procedures, but there are a few spots of good news. Among the HCPCS codes are three new and welcomed additions: laparoscopic cholecystectomy codes 47562, 47563 and 47564. With each code reimbursed at $1,885.06, lap chole may be a procedure that you're considering adding to your case mix — especially if you're already offering laparoscopy. While some have voiced safety concerns about performing lap choles in the outpatient setting, recent research shows that it can be safe and cost-effective if you carefully select patients. Here's what the experts say you should know.

2008 Lap Chole Codes

HCPCS Code

HCPCS Code Payment Rate

Medicare Pays

Patient Pays

47562
Laparoscopy, surgical; cholecystectomy

$1,885.06

$1,508.05

$377.01

47562
Laparoscopy, surgical; cholecystectomy

$1,885.06

$1,508.05

$377.01

47564
Cholecystectomy with exploration of common duct

$1,885.06

$1,508.05

$377.01

Preparing for risks
No one would deny that laparoscopy leads to a faster recovery than an open procedure. An hour-long lap chole doesn't require the abdominal muscles to be cut, resulting in less pain, quicker healing, less scarring and fewer complications such as infection. But what about cost? In a presentation at the American College of Surgeons 93rd Clinical Congress in New Orleans in October, the data from about 40,000 patients added up to one conclusion: Laparoscopic cholecystectomy is less expensive when it's done in ASCs. Specifically, the average cost was $6,208 for the approximately 1,500 patients who were treated in ASCs compared to $10,786 for the more than 38,000 patients treated in hospitals.

"Although there may be slightly higher rates of common duct injury with laparoscopic cholecystectomy, the absolute risk is very low, and the advantages of the laparoscopic approach generally outweigh this risk," says the study's author, Ian Paquette, MD, a surgical resident at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Consider the populations in each arm, says Douglas Smink, MD, co-author of the study and an instructor in surgery at Harvard Medical School in Boston. The study found that the ASC patients tended to be younger (their mean age was 45 compared to 49 in the hospitals), less likely to be diagnosed with acute cholecystitis (4.8 percent versus 8.26 percent) and had lower rates of co-morbities such as diabetes and heart disease. That's why careful patient selection in an ASC is important, says Dr. Smink. He adds that having to transfer the patient to the hospital would eliminate any potential benefits derived from patient satisfaction or economic savings.

"When screening, you need to look for acute cholecystitis because those patients need to be treated in the hospital," he says. "After that, look for anything that would make laparoscopy difficult, such as prior abdominal surgeries. Also look for any co-morbidities, such as heart or lung diseases, that would make the patient less likely to tolerate general anesthesia."

Even with a screening protocol, it's crucial to have a mechanism in place to transport the patient to a higher level of care if problems arise, says Jeffrey Hazey, MD, assistant professor in the Department of Surgery at Ohio State University Medical Center in Columbus. This system must move like a well-oiled machine, he says, to ensure patients get to the hospital safely and expeditiously if they need admission or advanced care.

"If the patient has a problem, or he needs additional therapy, he must be admitted to a hospital for overnight observation," he says. "There are some patients who you wouldn't anticipate needing an inpatient stay that will, and some that may need a conversion to an open procedure."

Goodbye, Gall Bladder

Here are a few tips from Philip Weber, MD, a surgeon at the Comprehensive Center for Laparoscopic Surgery in White Plains, N.Y., that can make the extraction process more efficient:

  • Tools of choice. Some surgeons may prefer using a spatula, scissors or scalpels for the procedure, says Dr. Weber. "I find that harmonic scalpels allow me to remove the gall bladder with very little bleeding," he says. "The liver bed can ooze quite a bit when you're moving a gall bladder with a cautery, so using the harmonic scalpel lets us decrease our operating time."
  • Assuming the position. It can be difficult to expose the gall bladder in heavier patients. To solve this problem, Dr. Weber suggests raising the table into a reverse Trendelenberg position to let the patient's colon and ileum fall forward. After that, he rotates the patient to the left to get better exposure.
  • Improving the view. To get a better look at the gall bladder when treating obese patients, Dr. Weber says he uses a 30-degree endoscope to look down and sideways during the procedure.
  • Proper removal. The gall bladder must be retracted laterally, says Dr. Weber, not in an upward motion. Otherwise, he says the patient is at a high risk for clots and the surgeon may mistake the hepatic duct for a stone.

— Nathan Hall

Quicker for surgeons, too
A laparoscopic procedure will take the same amount of time whether it's performed in a hospital or ASC, says Dr. Hazey, but certain variables may draw surgeons to freestanding centers. There surgeons don't have to face the "pull and tug" from logistical problems or worry about being called away for emergencies, having their scheduled rooms switched at the last minute or other problems that are common to hospitals, he says.

"We can do three or four procedures there in the time it'd take us to do one or two at a hospital," he says. "At hospitals, you have much longer staff turnover times."

The problem with turnover in hospitals, says Dr. Hazey, is that many hospitals have their nurses, housekeepers and anesthesia personnel work a set shift. If they're not finished when their shift ends, they still leave and let new staffers come in to finish the job. In contrast, most ASCs have their staffers there until the job is completed. "This gives the ASC staffers an incentive to get the job done quickly," he says.

Since cholecystectomy was one of the first procedures to be performed laparoscopically, Dr. Smink says the instruments needed are largely standardized. The more specialized devices for cholecystectomy, he says, include a laparoscope and camera as well as dissectors to fit through the trocars common to endoscopic surgical centers.

Perhaps the only step that can be removed from laparoscopic cholecystectomy is the use of an intraoperative cholangiogram during the procedure, says Dr. Hazey. There is some debate over whether it's necessary, especially since most surgeons use "selective" intraoperative cholangiograms in their algorithm of care to monitor patients who may be at a higher risk. "Eliminating the intraoperative cholangiogram can make the procedure quicker and cheaper," he says.

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