HYSTEROSCOPIC STERILIZATION
New devices do not require abdominal access or general anesthesia, and offer rapid recovery
IN THIS ARTICLE
Do benefits outweigh costs?
The overall cost of hysteroscopic sterilization methods compares favorably with laparoscopic approaches. The expense of the disposable equipment is recouped by avoiding the costs of general anesthesia, and operating room and facility charges.
Advantages of the office setting
Payment for physicians is slightly more than the reimbursement for laparoscopic sterilization performed in a facility.
The real benefit to ObGyns, however, is in moving the procedure into the office environment. This allows us great flexibility in scheduling, and avoids the “down time” required for traveling to a facility, waiting for operating room turnover, anesthesia, and paperwork.
Benefit to healthcare systems. Researchers in closed healthcare systems have analyzed the expenses associated with Essure compared with laparoscopic tubal sterilization. When all costs associated with hysteroscopic sterilization are considered, including the need for additional procedures (when the tubes are not accessible or the procedure fails) and the 3-month hysterosalpingography, there remained a significant savings to the healthcare system for these procedures, compared with laparoscopic techniques.2
Ask women who are currently using contraceptive steroids about their menstrual cycles before they started hormonal birth control. Remind women who had menorrhagia or irregular cycles that no method of sterilization will manage their cycles.
The addition of endometrial ablation to the hysteroscopic sterilization procedure is an option.3 However, only 1 of the global ablation technologies currently has FDA approval for concomitant treatment with Essure: Thermachoice (Ethicon Women’s Health and Urology; Somerville, NJ).
Alternatives to permanent sterilization
In counseling women about permanent sterilization, it is important to cover the alternatives, as well.
IUDs. We should also consider the levonorgestrel-containing intrauterine device (IUD), Mirena (Berlex; Montville, NJ), for patients with menorrhagia who desire long-term contraception. Studies have demonstrated excellent patient satisfaction with this system and reduction in menstrual blood loss equivalent to endometrial ablation.4 Although not a permanent solution, the IUD does provide superb contraception, failure rates are similar to sterilization, and management of menorrhagia is excellent, and the cost is less than 10% of a combined endometrial ablation and sterilization procedure. The ParaGard copper-containing IUD is a good choice for women with normal or light flow, but not for those with heavy cycles.
Systemic hormone methods. For women willing to consider systemic hormones, Depo-Provera or the Implanon implantable rod provide excellent long-term contraception.
Vasectomy. Remember that vasectomy remains an option; however, many women want the assurance that they are in control.
Coding and insurance
The difference in payment for hysteroscopic sterilization can be considerable, depending on the site. When performed anywhere other than your office, payment for use of the facility, medications, personnel, and equipment goes to the facility, whether an ambulatory surgery center or a hospital. When we do these procedures in our offices, our reimbursement reflects the fact that we are using our office space, exam table, equipment, supplies, and personnel.
When considering where to perform hysteroscopic sterilization, remember that no one is paying for our space, personnel, and equipment when we are not in the office. Therefore, there is a great advantage in getting our overhead reimbursed when we perform procedures in the office.
The total relative value units payable to the physician for the new CPT code 58565 (hysteroscopy, surgical, with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants), which is the code for all systems currently under study:
- 12.12 if performed in a facility
- 57.91 if performed in the office
Most payers cover hysteroscopic sterilization when the policy covers sterilization. Determination of coverage by Medicaid has been secured in at least 36 states.
Past the tipping point
It is time to begin to adopt this technology into routine gynecology practice, for the benefits it offers patients, and practicing surgeons, as well. The data are accumulating on the safety and effectiveness of hysteroscopic sterilization techniques—more than 50,000 procedures have been performed worldwide, and we have 5 years of data.
An apt analogy. Although it is true that we might initiate this approach in up to 10% of women who may ultimately require laparoscopy, there appears to be little downside to the attempt. I would suggest the analogy of attempting an endometrial biopsy in the office in lieu of a D&C under anesthesia for postmenopausal women.
True, we sometimes fail, but for the vast majority of patients, it is clearly beneficial to attempt the office procedure and avoid anesthesia. Similarly, by avoiding abdominal access and general anesthesia for sterilization, we are providing a safer and more pleasant procedure with rapid recovery for our patients. Those few who require a different approach will have invested little time, energy, effort, or risk if we learn to perform hysteroscopic sterilization in the office setting.
