Chiara F. Sugrue, MBA, MS, SCT(ASCP)
Chiara F. Sugrue, MBA, MS, SCT(ASCP)
Chiara F. Sugrue, MBA, MS, SCT(ASCP)
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CHIARA SUGRUE, <strong>MBA</strong>, <strong>MS</strong>, <strong>SCT</strong>(<strong>ASCP</strong>)CMIAC<br />
DIRECTOR, CLINICAL OPERATIONS, CYTOPATHOLOGY DIVISION<br />
ASSISTANT PROFESSOR NSLIJ‐HOFSTRA MEDICAL SCHOOL<br />
NORTH SHORE–LIJ HEALTH SYSTEM<br />
LAKE SUCCESS, NEW YORK<br />
THE NEW BREED OF<br />
CYTOTECHNOLOGISTS
I have nothing to disclose<br />
2
EXTENDED ROLE OF CYTOTECHNOLOGISTS<br />
1. Screening and interpretation: Gyn, Non‐Gyn, FNA<br />
• Screening IHC<br />
2. FNA Adequacy Assessment: superficial, CT scan, EBUS, EUS<br />
• Ultrasound assistance<br />
• Effective communication with clinicians<br />
3. Quality control/assurance<br />
4. Molecular testing: HPV, EGFR<br />
5. FISH: Urovysion<br />
6. Circulating Tumor Cell Testing<br />
7. Grossing<br />
8. Education, as part of the academic team in Pathology<br />
Residency & Cytopathology Fellowship<br />
3
FNA Rapid On‐Site Assessment of Adequacy<br />
(FNA ROSA) performed by Cytotechnologists<br />
STAKEHOLDERS<br />
• Patients<br />
• Laboratory Professionals<br />
• Laboratory Administrators<br />
• Medical Specialists (Radiology , ENT, Oncology, etc)<br />
• Payers<br />
4
FNA Rapid On‐Site Assessment of Adequacy<br />
(FNA ROSA) performed by Cytotechnologists<br />
ADVANTAGES<br />
• Allows appropriate specimen triage<br />
• IHC, Flow cytometry, Microbiology, Tissue bank for<br />
microRNA,<br />
• Reduces cost of patient care<br />
• Decreases number of unsatisfactory specimens<br />
• Decreases number of unnecessary surgery<br />
• Improves communication with clinicians<br />
• Allows better collection of clinical history<br />
• Brings the lab to the patient<br />
• “It is the right thing to do for the patient”<br />
5
Brigham & Women’s Hospital Cancer Cytopathology 2011<br />
Results<br />
• The accuracy of on‐site adequacy evaluation by<br />
Cytotechnologists = 93.2% to 96.5%.<br />
• The number of FNA on‐site adequacy evaluation increased<br />
annually by 11% on average (2003‐2009)<br />
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FNA Rapid Onsite Assessment of Adequacy:<br />
The Experience of an Academic Institution<br />
Gobara N, Liang L, Wasserman P, Morgenstern N, <strong>Sugrue</strong> C<br />
North Shore‐LIJ Health System (Poster # 116 ‐ ASC 2011)<br />
Results<br />
• The accuracy of on‐site adequacy evaluation by<br />
Cytotechnologists = 94.8% to 95.9%<br />
• The number of FNA on‐site adequacy evaluation increased<br />
cumulatively by 59% (2008‐2010) ‐ by 49% for 2011<br />
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North Shore-Long Island Jewish Health System Hospitals<br />
<br />
NSUH-Glen Cove<br />
<br />
<br />
<br />
Huntington Hosp<br />
<br />
<br />
<br />
<br />
Lenox Hill<br />
<br />
NSUH-Forest Hills<br />
Bayside<br />
<br />
<br />
<br />
NSUH-Manhasset<br />
CORE<br />
LIJ Jewish Med Ctr<br />
Med Ctr<br />
Franklin Hospital<br />
<br />
NSUH-Syosset<br />
<br />
NSUH-Plainview<br />
<br />
Southside Hospital<br />
<br />
<br />
SIUH-Concord<br />
<br />
SIUH North<br />
<br />
<br />
Peninsula Hospital<br />
SIUH South<br />
<br />
Prepared by NSLIJHS Planning Office, 1/10/02
FNA TEAM @ NSLIJHS Laboratories<br />
From left:<br />
Ryan Brenkert, Xin Ding, Sean McNair, James Rankin, Constantinos Coutsouvelis,<br />
Daniel Soto, Karen Chow, Antoinette Lugo<br />
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It is evidence‐based knowledge that…<br />
Cytotechnologists are highly competent<br />
in performing FNA Rapid On-site<br />
Assessment of Adequacy<br />
10
FNA Rapid On‐Site Assessment of Adequacy<br />
(FNA ROSA) performed by Cytotechnologists<br />
DISADVANTAGES<br />
• Lab productivity loss<br />
• Inadequate service compensation<br />
• Lack of CPT codes for service by Cytotechnologists<br />
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DISADVANTAGE<br />
Lab productivity loss<br />
1. Time average for FNA ROSA = 45‐60’<br />
(excluding traveling time). Duration influenced by:<br />
Specimen types<br />
Nature of the lesion<br />
Type of procedure (EBUS, EUS, CT scan)<br />
Operator experience<br />
2. Time away from screening<br />
12
Lab productivity loss: example<br />
Specimen Type CPT code Medicare<br />
Rate for NY<br />
(TC)<br />
Pap test<br />
(LBP)<br />
Pap test<br />
(w/Imaging)<br />
Urine<br />
(LBP)<br />
Case/hour<br />
Total<br />
Reimbursement<br />
88142 $ 28.51 10 $ 285.10<br />
88175 $35.06 10 $350.60<br />
88112 $ 59.07 9 $ 531.63<br />
FNA 88173 $ 88.60 2.5 $ 221.50<br />
Average<br />
per hour<br />
$ 347.21<br />
Average lab reimbursement for 1 hour<br />
Cytotechnologist screening work = $347.21<br />
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Lab productivity loss: example cont.<br />
Loss of screening productivity = ($ 347.21)<br />
FNA reimbursement (CPT 88173) = $ 165.19<br />
Lab productivity loss for<br />
7<br />
www.cms.hhs.org<br />
14
DISADVANTAGE:<br />
Inadequate service compensation<br />
CPT code<br />
Medicare Rate<br />
for NY<br />
(TC)<br />
Note<br />
88172TC $10 Supplies<br />
88177 N/A Each additional<br />
evaluation episode<br />
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Additional considerations:<br />
Reduced lab reimbursement in near future<br />
• Do more with less<br />
Improve efficiency<br />
Increase financial performance<br />
Expand quality measures, decrease TAT<br />
• Challenges in shifting Cytotechnologists’ billable to<br />
non‐billable services<br />
• Do the right thing for the patient<br />
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• New ways to apply technology<br />
• New ways of looking at multidisciplinary<br />
collaborations<br />
• New ways for continuing to provide value to<br />
the patients and to the lab<br />
Business as usual is not an alternative<br />
17
Option 1:<br />
Adoption of Telepathology<br />
• Increasingly implemented for direct patient care<br />
• 2007 CAP – General Checklist<br />
<br />
<br />
<br />
Primary diagnosis<br />
Frozen sections diagnosis<br />
Formal second‐opinion consultations<br />
• 2010 CAP ‐ Anatomic Pathology Checklist added Digital<br />
Image Analysis section<br />
DNA , Morphometric analysis, FISH<br />
• FNA on‐site adequacy assessment<br />
<br />
<br />
<br />
<br />
Absence of specific regulation and practical guidelines<br />
Validation required for the intended use<br />
Initial capital expense<br />
Dependent on 2 operators<br />
18
Telepathology validation<br />
at NSLIJHS Laboratories<br />
19
Option 2:<br />
Conversation with Medical Specialists<br />
• Can we share the responsibility of hiring a<br />
Cytotechnologist<br />
CYTOPATHOLOGY<br />
) Provide Training<br />
Competence<br />
Performance Appraisal<br />
Continuing Education<br />
MEDICAL SPECIALISTS (i.e. RADIOLOGY)<br />
Provide<br />
Salary & Benefit<br />
20
Option 3:<br />
Propose a new CPT code for FNA ROSA<br />
performed by Cytotechnologists<br />
CTs have enormously expanded the scope of service<br />
in the last decade & acquired highly specialized skills<br />
Master ‐ Cytotechnology programs<br />
Shortage of Pathologists in the US<br />
• Delegation of routine work to Cytotechnologists and<br />
Pathology Assistants<br />
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Propose a new CPT code for FNA ROSA<br />
performed by Cytotechnologists cont.<br />
• Accepting the reimbursement system as<br />
immutable is not in the profession best interest<br />
• Changes in AMA recommendation and C<strong>MS</strong><br />
approval will require hard work<br />
• When Pathologists and Cytotechnologists work<br />
as team better outcome better<br />
patient care<br />
• As professional organization, we should become<br />
the agent of change.<br />
22
New model for FNA rapid on‐site<br />
Assessment of Adequacy by Cytotechnologists<br />
• Brings the lab to the patient<br />
• Adds value to the lab<br />
Holistic pursuit<br />
• Maintains lab presence in the patient‐centered<br />
team<br />
• Creates an institutional logic<br />
THANK YOU<br />
23
References<br />
• Burlingame OO, Kesse’ KO, Silverman SG, Cibas ES. On‐Site Adequacy Evaluation performed by Cytotechnologists: Correlation with final<br />
Interpretation of 5241 image‐guided Fine Needle Aspiration Biopsies. Cancer Cytopathol. 2011.<br />
• Eedes CR, Wang HH. Cost‐effectiveness of immediate specimen adequacy assessment of thyroid fine‐needle aspirations. Am J Clin Pathol. 2004;<br />
121: 64‐69<br />
• Nasuti JF, Gupta PK, Baloch ZW. Diagnostic value and cost‐effectiveness of fine‐needle aspirations specimens: review of 5,688 cases. Diagn<br />
Cytopathol. 2002; 27: 1‐4<br />
• Andonian S. Okeke Z. Okeke DA, <strong>Sugrue</strong> C, Wasserman PG, Lee BR. Number of needle passes does not correlate with the diagnostic yield of<br />
renal fine needle aspiration cytology. J Endourol. 2008; 22: 2377‐2380.<br />
• Alsohaibani F, Girgis S, Sandha GS. Does onsite Cytotechnology evaluation improve the accuracy of endoscopic ultrasound‐guided fine‐needle<br />
aspiration biopsy Can J Gastroenterol. 2009;23: 26‐30<br />
• Layfield LJ, Bentz JS, Gopez EV. Immediate on‐site interpretation of fine‐needle aspiration smears: a cost and compensation analysis. Cancer.<br />
2001; 93: 319‐322.<br />
• Gupta PK. Progression from on‐site to point‐of‐care fine needle aspiration service: Opportunities and challenges. CytoJournal. 2010; 7:6<br />
• Dhillon I, Pitman MB, DeMay RM, Archuletta P, Shidham V. Compensation crisis related to the onsite adequacy evaluation during FNA<br />
procedure. Urgent proactive input from Cytopathology community is crucial to establish appropriate reimbursement for CPT code 88172 (or<br />
its new counterpart if introduced in the future). CytoJournal 2010; 7:23<br />
• Al‐Abbadi MA, Bloom LI, Fatheree LA, Haack LA, Minokowitz G, Wilbur DC, Austin MR. Adequate reimbursement is crucial to support costeffective<br />
rapid on –site Cytopathology evaluations. CytoJournal 2010; 7:22<br />
• Davey DD, Neal MH. Coding charges in the United States front and center: Implications for Cytopathology. Cancer Cytopathol. 2011.<br />
• Ghofrani M, Beckman D, Rimm DL. The value of onsite adequacy assessment of thyroid fine‐needle aspirations is a function of operator<br />
experience. Cancer Cytopathol. 2006; 108: 110‐113.<br />
• American Medical Association. Pathology and Laboratory. In CPT ® (Current Procedural Terminology) 2011 Professional Edition. Chicago:<br />
American Medical Association; 2010: 433‐435.<br />
• US Department of Health and Human Services, Center for Medicare and Medicaid Services. 2011 MLN Matters Articles, MM7727.<br />
http://www.cms.gov/MLN‐MattersArticles/2011Mman.<br />
• Zhu W, Michael CW. How important is onsite adequacy assessment for Thyroid FNA: An evaluation of 883 cases. Diagn Cytopathol. 2007;35:<br />
183‐186.<br />
• Woon C, Bardales RH, Stanley MW, Stelow EB. Rapid Assessment of fine needle aspiration and final diagnosis: How often and why the<br />
diagnoses are changed CytoJournal 2016; 6:25.<br />
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