The TRUCLEAR Hysteroscopic Morcellator (Smith & Nephew) was FDA-approved in 2005 as the first intrauterine mechanical morcellator (VIDEO 4). It requires a dedicated fluid pump and has different instrumentation for myomas and polyps. For myomas, the instrument consists of a rotating tube that reciprocates within an outer 4-mm tube. Both tubes have windows at the end with cutting edges. A vacuum connected to the inner tube provides controlled suction that pulls the tissue into the window on the outer tube and cuts it as the inner tube rotates (VIDEO 5).
For polyps, both inner and outer tubes have oscillating serrated edges on each window (VIDEO 6).
Both instruments are used through a 9-mm offset rod-lens continuous-flow hysteroscope.
In a retrospective analysis, the TRUCLEAR morcellator reduced operative time by about two thirds for polyps and one half for Type 0 and Type I myomas, compared with monopolar loop resection.15 A later study of inexperienced ObGyn residents demonstrated shorter operative times and lower total fluid deficits for the TRUCLEAR morcellator, compared with resectoscopic procedures overall, during polypectomy and myomectomy of Type 0 and Type I myomas.16
Smith & Nephew recently introduced a smaller set of instruments, including a 2.9-mm blade for removal of polyps through a 5.6-mm continuous-flow hysteroscope. However, the new instruments have not yet been approved by the FDA and are unavailable within the United States.
Option 2: MyoSure
The MyoSure Tissue Removal System (Hologic) was FDA-approved in 2009. The hand piece is a rotating and reciprocating 2-mm blade within a 3-mm outer tube. The cutter is connected to a vacuum source that aspirates resected tissue through a side-facing cutting window in the outer tube. The system utilizes standard hysteroscopy set-up for fluid inflow and suction. The instrument is placed through an offset lens continuous-flow hysteroscope with an outer diameter of
6.25 mm. The smaller diameter reduces the amount of cervical dilation required, as well as the risk of uterine perforation.
The smaller size of the instrument renders it ideal for an office setting. Miller and colleagues demonstrated its safety and efficacy for office removal of polyps and myomas (VIDEO 7; VIDEO 8).17
Inadequate reimbursement?
Although both morcellators simplify hysteroscopic myomectomy and polypectomy, insurance reimbursement does not yet differentiate between places of service—unlike other in-office procedures that take into account the cost of the procedural device (see “Reimbursement is limited for hysteroscopic myomectomy in an office setting”). Until the relative value unit (RVU) is modified to reflect this cost, office use of the hysteroscopic morcellator for myomectomy and polypectomy will be financially restrictive to the gynecologist in private practice. Nevertheless, both instruments are easy to use and offer improved safety, increasing access to uterine-preserving surgery.
Thanks to Dr. Andrew I. Brill and Dr. William H. Parker for their thoughtful review of this article.
Reimbursement is limited for hysteroscopic myomectomy in an office setting
Since the inception of the resource-based relative value scale, the Centers for Medicare and Medicaid Services (CMS) have provided for different levels of payment to physicians, depending on the place of service and the extent of work involved. The relative value units (RVUs) established for each clinical service are based on three components:
- physician work
- practice expense
- malpractice expense.
The practice expense includes supplies, equipment, clinical and administrative staff, and renting and leasing of space.
When a physician provides a service in a hospital setting or outpatient clinic or surgery unit, the practice expense is lower because the hospital or outpatient facility shoulders those costs. In an office setting, however, the physician practice incurs the full expense of providing the service. In most cases, therefore, the practice is reimbursed at a higher total RVU for office procedures.
The “place of service” code required on your claim form lets the payer know whether the service was rendered in your office (code 11) or a facility such as a hospital or outpatient surgery center (codes 21–24). Physicians who work out of a hospital-owned facility—i.e., physicians who are employed by a hospital—would bill for a facility place of service rather than an office.
The difference in RVUs can be significant. For example, hysteroscopic sterilization (CPT code 58565) has two different RVUs, depending on whether the service is performed in a facility or office (TABLE). However, although hysteroscopic myomectomy can now be safely performed in the office setting for small, less invasive myomas, CMS has not yet assigned a place of service differential for this procedure (CPT code 58561). In other words, CMS has determined that hysteroscopic myomectomy—by definition or practice—is rarely or never performed outside a hospital or outpatient facility.
Medicare reimbursement for hysteroscopic procedures
| Procedure | CPT code | Relative value units | |
|---|---|---|---|
| Facility | Office | ||
| Sterilization | 58565 | 12.90 | 56.66 |
| Endometrial ablation | 58563 | 10.23 | 52.05 |
| Cryoablation | 58356 | 10.34 | 58.92 |
| Myomectomy | 58561 | 16.33 | NA |
| Polypectomy (with dilation and curettage, biopsy) | 58558 | 7.95 | 10.60 |
| To determine reimbursement, multiply the RVU by the Medicare conversion factor, which is $33.9764 | |||
When contracting with a private payer, be sure to ask how the payer reimburses for hysteroscopic myomectomy in an office setting. Payers that do not include a place of service differential may be amenable to negotiation if you can demonstrate that extra compensation can actually save them money and maintain high-quality patient care.
—Melanie Witt, RN, CPC, COBGC, MA
Ms. Witt is an independent coding and documentation consultant and former program manager, department of coding and nomenclature, American Congress of Obstetricians and Gynecologists.