Bringing Endoscopic Ultrasound (EUS) to Your Ambulatory Surgery Center (ASC): A Roadmap to Success

What does it take to implement EUS in our center?

The integration of endoscopic ultrasound (EUS) capabilities into ambulatory surgery centers (ASC) represents a significant opportunity for facility growth, enhanced patient care, and improved financial outcomes. Historically, numerous barriers, including high equipment costs and specialized training requirements, have confined EUS procedures to academic hospitals, tertiary care centers or both. This limitation has restricted patient access to this valuable diagnostic and therapeutic modality.  In the past few years, physicians, administrators, and owners have seen the value of EUS in the ASC; and because of some of today’s product breakthroughs, it is even more appealing.

This white paper provides ASC leaders, physicians, and administrators with a comprehensive roadmap for successfully implementing EUS in the ASC. With recent technological advancements resulting in cost efficiencies, ASCs now have unprecedented opportunities to incorporate these procedures efficiently and profitably.

The following guide addresses critical implementation aspects, including:

  • Financial considerations and return on investment
  • Equipment and technical requirements
  • Patient selection criteria
  • Staff training and responsibilities
  • Billing and reimbursement strategies
  • Operational best practices for success


The Economics of EUS in ASCs: Understanding what it can bring to your ASC


Potential Costs:

Capital expenditures have traditionally confined EUS procedures to hospital settings with higher procedure volumes and larger capital budgets. This limitation has created accessibility gaps for patients who could benefit from these procedures in the more convenient, preferred, and often more cost-effective ASC environment.

Implementing EUS in the ASCs has been expensive (see Table 1). Traditional ultrasound scanners cost $200,000+, multiple specialized echoendoscopes at $80,000+ each, dedicated service costing $10,000 have all amounted to about $400,000 total, with a significant investment in that first year, often totaling more than $250,000.

In contrast, the innovative EndoSound Vision System™ (EVS™) offers a fully functioning EUS system with a highly portable ultrasound scanner and capital equipment at significantly lower cost ($50,000) (Table 1).  The EVS does not have an annual service contract and there are no expensive echoendoscopes to purchase.

Component Traditional Systems EVS
Processors/Scanners $200,000+ $50,000
Echoendoscopes $80,000 each (minimum 2 needed) Converts existing endoscopes
Annual Service $10,000+ per scope per year Reduced maintenance costs
Training Extensive specialist training Personalized training service


Potential Revenue:

One aspect of the financial picture is the amount of reimbursement for EUS versus EGD.  Simply compared, EUS procedures, on average, reimburse $864* per Medicare case; standard EGDs reimburse $503* per Medicare case.  The potential to almost double procedure revenue is clear.

For many facilities, the revenue potential extends beyond these base numbers when considering:

  1. Private payer rates: Typically, higher than Medicare rates, often by 15-30%
  2. Transitional Pass-Through (TPT) payments: Additional reimbursement for innovative devices (which the EVS has for its disposable component)
  3. Reduced referral leakage: Retention of patients who would otherwise be referred to hospitals
  4. Increased physician satisfaction: Enhanced recruitment and retention of specialists
  5. Market differentiation: Competitive advantage over other ASCs in the region

ASCs implementing EUS with newer, more cost-effective technologies like the EVS can typically expect initial investment recovery quicker, long-term revenue enhancement, operational efficiencies, maintaining optimal cash flow and predictable financial planning.

Technical Requirements    

With EUS in your ASC, understanding the equipment, room, and staff requirements are crucial. To date, it has been a burden to get EUS in the ASC because the equipment has been bulky and big, and not easily transportable.  Endosound and EVS solve these issues (see below) and make preparation to perform EUS in your ASC seamless.

Start with acquiring an EUS system, including an ultrasound processor and compatible echoendoscopes. You’ll need at least two scopes: linear echoendoscopes and potentially FNA and FNB needles.  Look at several systems and their costs.  Remember, the EVS was designed with this distinct price burden in mind.  Moreover, you will convert your existing gastroscopes into EUS-capable devices.   The EVS is a portable system (easily moved between rooms) that works with your current equipment, and our probe eliminates the need for multiple specialized scopes.

Allocate a dedicated room with adequate space for ultrasound equipment and monitors. Verify proper electrical and network connections. Just like your reprocessing for current scopes, the EUS scopes will follow similar protocols.  For the EVS, its footprint is smaller than existing EUS systems, and the probe (UTM) has a simplified reprocessing protocol (no working channel means easier, safer cleaning). Lastly, and importantly, we train your staff on EUS-specific equipment, procedures, and staff responsibilities during the procedure, and cleaning and reprocessing.  With our highly experienced and dedicated team, we’ll be with you every step of the way.

Reimbursement, Billing and Add-On payments 

Even though you know this well, when billing for endoscopic procedures in ASCs, facility fees cover several key elements:

  • ASC facility usage (operating rooms, recovery areas, waiting rooms)
  • Services from nurses and technical staff
  • Drugs and biologicals not separately paid under OPPS

Physicians bill their professional services separately through consultations, evaluations, and follow-ups. ASCs use CPT and HCPCS Level II codes, with payments typically calculated as a percentage of hospital rates.

Maximizing Reimbursement Success

For optimal reimbursement:

  • Review private payer contracts thoroughly
  • Ensure EUS procedures are included in the contract language
  • For multiple procedures, remember the first is billed at full rate, with subsequent procedures may be reduced by 50%
  • Maintain compliance with all billing regulations
  • Implement pre-authorization processes for high-value procedures and develop a process for claims denials


Specific Codes for EUS and the EVS

When billing specifically for EUS procedures, including the EVS, there are several CPT codes.

CPT Code Description
43231 Esophagogastroduodenoscopy with endoscopic ultrasound examination
43232 Esophagogastroduodenoscopy with endoscopic ultrasound examination and fine needle aspiration
43237 Endoscopic ultrasound examination, esophagus, stomach, and duodenum
43238 Endoscopic ultrasound examination with fine needle aspiration, esophagus, stomach, and duodenum
43242 Endoscopic ultrasound examination, pancreaticobiliary with fine needle aspiration
43253 Endoscopic ultrasound-guided transmural injection
43259 Endoscopic ultrasound examination of esophagus, stomach, and duodenum
43240 Esophagogastroduodenoscopy with transmural drainage of pseudocyst


Transition Pass Through Payment Code – Additional Reimbursement Opportunity

The EVS received a Transition Pass Through (TPT) payment code from CMS in July 2024. The TPT code, C1606, provides additional reimbursement for the disposable component of the EVS under the Medicare Hospital OPPS and ASC Payment System.

This specialized pathway is designed to adequately compensate healthcare facilities for the cost of adopting cutting-edge technologies like EVS, allowing for an add-on payment along with the standard CPT codes.

This additional payment has been important for new centers evaluating EVS and is exclusively tied to the EVS.

Preparing Your ASC and Staff for Successful EUS Implementation

To ensure your staff and center are well-prepared for EUS procedures, here are some key insights the EndoSound team has gathered during installations across the US and Latin America.

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Establishing a True Partnership

While “partnership” is often used to describe industry-center collaborations, implementing EUS in your ASC requires genuine open dialogue. True partnership means both parties have a shared investment in your program’s success, making communication essential. At EndoSound, our risk-sharing partnership is the first of its kind.

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GI Tech Development

Training ASC technicians without EUS experience is essential for them to reach the proficiency level of their hospital counterparts.  We train techs on the EVS and in collaboration with our clinicians, the basics around EUS. Our team is present during the entire installation and always available when called upon post installation.

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Billing Resource Assistance

Your industry partner should offer support with appropriate procedure codes and share reimbursement insights from other facilities. This collaborative approach helps your billing department navigate coding, reimbursement pathways, and payer contracting more effectively. EndoSound involves health economic experts to assist our clients and will introduce prospective centers to reference customers regarding this process.

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Ongoing Expert Support

Implement direct communication channels with your industry partner that extend well beyond initial installation. Whether through phone calls or video conferencing, this continuous access provides critical support during pre-procedure preparation, procedural questions, and post-procedure evaluation. Your industry partner should be committed to a long-lasting partnership that goes beyond initial installation.

Conclusion: The Future of EUS in the ASC Setting

The integration of EUS into the ASC environment represents a significant advancement in patient care, clinical capability, and business opportunity. With innovative technologies like the EVS reducing traditional barriers to entry, ASCs now have unprecedented access to this valuable diagnostic and therapeutic modality.

By following the comprehensive roadmap outlined in this white paper, facilities can navigate the implementation process successfully, avoiding common pitfalls while maximizing clinical and financial outcomes. Key factors that will lead to success include:

  • Thorough planning and preparation
  • Investment in staff development and training
  • Strategic partnerships with vendors and healthcare institutions
  • Attention to reimbursement and billing

As healthcare continues to shift toward value-based models and patient-centered care, the ability to offer advanced procedures like EUS in convenient, cost-effective settings is increasingly important. Early adopters of these capabilities will be well-positioned to lead in this evolving landscape, providing enhanced care while building sustainable competitive advantages.

 

About EndoSound

EndoSound offers a revolutionary system that transforms standard endoscopes into EUS devices, improving patient care while reducing healthcare costs. The EVS is designed to address the historical barriers to EUS implementation in the ASC setting, making this valuable technology accessible to more facilities and patients.

Learn more at www.endosound.com or call (971) 231-4791. Headquartered in Portland, OR.

 

This white paper is intended for informational purposes only and does not constitute medical, legal, or financial advice. Healthcare facilities should consult with appropriate professionals regarding specific implementation questions.

The Evolution and Promise of Echo-EGD: Enhancing Standard Endoscopy with Ultrasound

When a patient presents with abdominal pain or dyspepsia, physicians may choose from a variety of diagnostic tests to uncover the underlying cause. While standard EGD (esophagogastroduodenoscopy) is frequently utilized, Echo-EGD, which enhances traditional endoscopy with ultrasound, holds the promise of greater diagnostic accuracy.  It should be noted that Echo-EGD is distinguished from typical EUS indications, namely abnormalities noted on prior endoscopy or imaging for further evaluation.

The choice between standard EGD and Echo-EGD depends on the indication.  The follow-up and/or evaluation of lesions such as Barrett’s, gastric ulcers, etc. are common EGD indications.  However, there is also significant overlap i.e. patients referred for diagnostic evaluation of abdominal pain or dyspeptic symptoms which there is a significant percentage of patients. Of the 8 million EGDs performed annually in the United States, many patients could fall into the diagnostic category and could benefit from the enhanced visualization that Echo-EGD provides.  Indeed, many of these patients come to EUS after EGD and other diagnostic testing has been uninformative.

Standard EGD (Figure 1a) only visualizes the inner lining of the upper digestive tract. Adding ultrasound (Echo-EGD, or Echo-Endoscopy) allows physicians to visualize both the digestive tract lining and the surrounding tissues and organs during a single examination (Figure 1b).
 

Figure 1. (a) Illustration on left is of organs seen with standard EGD. (b) Illustration on right is of organs examined with Echo-EGD. This comprehensive view can improve diagnostic accuracy and potentially reduce the need for follow-up imaging.

Compelling Clinical Data

Echo-EGD is not a new concept. There are significant data dating back to 2000 showing clinical benefits (Table 1).  Echo-EGD has not been widely adopted, primarily due to the high costs of traditional endoscopic ultrasound (EUS) systems and their limitations in the hospital setting. However, with new technology like the EndoSound Vision System™ (EVS™), which can convert any endoscope into an EUS device at a lower price point, Echo-EGD has become more feasible.

Title Authors and Reference Implications for Echo-EGD (EE)
EUS to detect evidence of pancreatic disease in patients with persistent or nonspecific dyspepsia Sahai et al., Gastrointest Endosc 2000;52:153-9. EE demonstrated that 40% (51/156) of dyspepsia patients had evidence of pancreatic disease
An assessment of the potential value of endoscopic ultrasound as a cost-minimizing tool in dyspeptic patients with persistent symptoms Sahai et al., Endoscopy 2001; 33: 662–667 Dyspepsia evaluation had a lower cost with EE based approach
EUS in the management of uninvestigated dyspepsia Lee et al., Gastrointest Endosc 2002; 56: 842–848 EE changed management in 25% of dyspepsia patients
EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain Chang et al., Gastrointest Endos 2010; 72: 967-74 38% of patients with upper abdominal pain had a diagnosis made (66/172) (38%); of those  48% were EE based

 
Endosonography For Right-sided and Acute Upper Intestinal Misery: the EFRAIM study Jung et al., United European Gastro Journal 1(5) 329–334 223 patients with abdominal pain.  EE had a higher diagnostic yield than the combination of transabdominal US and EGD (62.3 vs. 50.7%; p = 0.001).

Table 1. Echo-EGD clinical publications

 

Why Echo-EGD Matters

  • In the US approximately 8 million standard EGDs are performed annually
  • Many of these are performed for diagnostic indications (e.g. abdominal pain, and/or dyspepsia) and these patients could benefit from the enhanced diagnostic capabilities where pathology was identified in as many as 35% of patients (Sahai et al., 2000).
  • Clinical evidence suggests that Echo-EGD as a first line diagnostic could be more effective in discovery of disease or the causes of the patient’s presentation.
  • Lastly, the procedure can be safely performed in ambulatory surgical centers (ASCs), and because of the introduction of the EVS, access to care can be improved and costs are reduced.

 

Echo-EGD: Time and Money

Figure 2. Comparison between patient flow on right with standard EGD first and Echo-EGD on left side.  Both time and money are saved with Echo-EGD.

 

When a patient comes in with abdominal pain and/or dyspepsia, they face two potential diagnostic paths – and the difference in both time and money is striking.

Standard EGD (“Traditional Approach”) (Figure 2 right side), often involves a multi-step diagnostic journey:

  • Week 1: Patient presents with upper abdominal pain
  • Week 2: Initial EGD (Insurance cost: $2,000, Patient cost: $400)
  • Week 5: Additional imaging like CT or MRI (Insurance cost: $2,000, Patient cost: $600)
  • Week 10: Hospital-based EUS (Insurance cost: $1,700, Patient cost: $340)

The standard EGD patient flow may stretch over 10 weeks, with total costs reaching $5,700* for insurance and $1,340* for the patient. The process requires multiple appointments, procedures, and recovery periods.


With Echo-EGD (Figure 2, left side), patients can benefit because it offers a streamlined diagnostic process. After the initial presentation of upper abdominal pain, by week 2, patients can receive a comprehensive examination that costs insurance $1,100 and the patient just $200. Clearly a more simplified path. This single procedure combines traditional endoscopy with ultrasound imaging, leading to a diagnosis within two weeks. Total cost: $1,320.*

The Bottom Line

In this example, the difference is clear – Echo-EGD saves:

  • 8 weeks of diagnostic time
  • $4,600 in insurance costs
  • $1,120 in patient out-of-pocket expenses
  • Multiple medical visits and procedures

These numbers are based on CMS national averages and are likely much higher for private payers.  Finally, this change in patient flow has the potential to reduce healthcare costs and improve patient’s lives.

Beyond the numbers, this represents less time spent uncertain, fewer medical procedures, and a more efficient path to treatment for patients seeking answers about their health.

As noted by Dr. Leonardo Sosa at IHU de Strasbourg, France, in his textbook titled Pancreatic Endoscopic Ultrasound: Current Practice and Clinical Applications 1st Edition, he states that the EVS is a:

“new and revolutionary upper endoscopy solution [that] offers the promise of “democratizing” internal sonography while performing EGD, making Echo-EGD [or Echo-Endoscopy] widely available to all patients with upper digestive symptoms. One could imagine a time when internal sonography will maximize the diagnostic yield of every upper endoscopy, providing visualization of luminal features and at the same time, adjacent, extra-luminal structures. This new device will probably increase the number of second-intention EUS worldwide for precision diagnostics and it will compete with tomography and abdominal ultrasound.”

The EVS enables physicians to perform Echo-EGD in the ASC, making this powerful diagnostic tool accessible to all patients with upper digestive symptoms. This innovation could transform standard endoscopy patient pathways by integrating enhanced imaging earlier in the diagnostic process. Revised clinical algorithms that incorporate Echo-EGD more frequently can deliver significant benefits to all stakeholders—reducing diagnostic timelines for patients, lowering overall healthcare costs for insurers, and creating more efficient workflows for providers.

 

*Cost estimates based on CMS, Google search.  Actual costs could be higher or lower in your state and clinic.

Revolutionizing Endoscopic Ultrasound in Ambulatory Surgical Centers: The EVS™ Advantage

Endoscopic ultrasound (EUS) has long been a valuable diagnostic and therapeutic tool in gastroenterology, traditionally confined to hospital settings due to high costs and technical requirements. This white paper introduces the EndoSound Vision System™ (EVS™), a groundbreaking solution that makes EUS accessible and profitable for Ambulatory Surgical Centers (ASCs) and smaller hospitals. By addressing traditional barriers to EUS adoption in outpatient settings, EVS is poised to transform the landscape of advanced endoscopy, improving patient care, physician satisfaction, and ASC profitability.

Background: EUS in Gastroenterology

Endoscopic ultrasound (EUS) has been a cornerstone of advanced gastroenterology for over three decades. This hybrid technique combines endoscopy with high-frequency ultrasound, allowing for detailed imaging of the gastrointestinal tract and adjacent structures. EUS has proven invaluable for:

  • Diagnosis and staging of gastrointestinal cancers
  • Evaluation of submucosal lesions
  • Assessment of pancreaticobiliary disorders
  • Guided fine-needle aspiration (FNA) and biopsy procedures
  • Therapeutic interventions such as pseudocyst drainage and celiac plexus neurolysis

Despite its clinical utility, EUS has primarily been confined to hospital-based settings due to several limiting factors.

Traditional Barriers to EUS in ASCs

Historically, several factors have prevented the widespread adoption of EUS in the ASC:

  1. High Capital Costs: Traditional EUS systems require substantial upfront investment, often exceeding $200,000 for the ultrasound hardware alone.
  2. Additional Scope Requirements: Conventional EUS systems necessitate the purchase of specialized echoendoscopes, which can cost over $80,000 each. This represents a significant additional expense beyond the ultrasound hardware.
  3. Extensive Training: The complexity of traditional EUS systems demands extensive training for endoscopy technicians, increasing operational costs and potential scheduling difficulties
  4. Space Constraints: Many ASCs lack the physical space to accommodate bulky EUS equipment, limiting their ability to offer this service.

These barriers have effectively relegated EUS to larger hospital settings, limiting access for patients and potentially increasing healthcare costs.

The EVS Solution

The EVS represents a paradigm shift in EUS technology, specifically designed to overcome the traditional barriers to ASC adoption. Key advantages include:

  1. Low Capital Cost: The EVS is offered at a fraction of the cost of traditional EUS systems, making it accessible to a wider range of healthcare providers. Furthermore, making the case for Echo-Endoscopy, the concept of combining upper endoscopy with EUS to maximize the diagnostic yield, is possible.
  2. Compatibility with Existing Endoscopes: Unlike traditional systems, EVS works with standard endoscopes already in use at ASCs. This eliminates the need for additional expensive echoendoscopes, allowing for immediate implementation regardless of the current scope vendor.
  3. High-Quality Imaging: Despite its cost-effectiveness, EVS provides high-resolution ultrasound images comparable to those produced by many traditional systems.
  4. Minimal Additional Training: The system’s user-friendly interface and compatibility with existing endoscopes minimize the learning curve for endoscopy technicians.
  5. Compact Design: The EVS’s small footprint allows for easy integration into existing ASC environments without requiring additional space. Additionally, it can be easily moved between room and can potentially be shared across facilities due to its compact size.

Financial Benefits for ASCs

Implementing the EVS can drive significant financial benefits for ASCs:

  1. Expanded Procedure Offerings: ASCs can now offer EUS procedures, attracting new patients and retaining existing ones who would otherwise be referred to hospitals.
  2. Increased Revenue: EUS procedures are reimbursed at the higher end of the EGD CPT code table, providing a new revenue stream for ASCs.
  3. Improved Utilization: The addition of EUS can help optimize underutilized ASC capacity, increasing overall procedure volume and profitability. As the EVS works directly with your existing equipment, setup and room turnover is minimal, allowing EUS exams to be performed within the standard block schedule without delay.
  4. Physician Satisfaction: By enabling gastroenterologists to perform advanced procedures in the ASC setting, the EVS can improve physician satisfaction and potentially attract new practitioners to the facility.

Case Study: Realizing the EVS Advantage

To illustrate the real-world impact of the EVS, consider the following case study from a current user:

An established gastroenterologist implemented the EVS in his ASC practice, with the following results:

  • Pre-Implementation (2023):
    • 112 EUS cases performed over 8.5 months in a hospital endoscopy suite.
  • Post-Implementation (2024):
    • 96 EUS procedures performed at the hospital endoscopy suite
    • 88 EUS cases performed at the ASC using the EVS
  • Total EUS Volume:

With EUS now available at the ASC, more patients were scheduled for expanded indications including chronic abdominal pain and diarrhea, pancreatic cancer screenings, pancreatic cyst surveillance, dilated bile ducts, small gastric submucosal lesions, and others.

Case Study—Key Outcomes:

1. Practice Growth through Echo-Endoscopy:

  • The physician didn’t simply shift volume but significantly expanded his EUS practice.
  • This was accomplished by screening more patients with EUS, a term called Echo-Endoscopy meaning “Ultrasound-Enhanced Endoscopy”.
  • Using EUS in conjunction with regular EGD has the potential to enhance diagnostic yield and data from this case study confirms that result.

2. ASC Revenue Boost:

  • EUS procedures code with higher reimbursement
  • Increased volume of EGD and colonoscopy procedures on days allocated for EUS. When physicians schedule EUS exams, they will often perform additional EGD and colonoscopy cases to fill out their schedule.

3. Improved Efficiency:

  • The EVS allowed for efficient scheduling and performance of EUS procedures in the ASC setting.

4. Enhanced Patient Experience:

  • Patients benefited from the convenience and typically lower costs associated with ASC-based procedures.

This case study demonstrates that implementing EVS can be a win-win situation for gastroenterologists, ASCs, and patients alike.

A New Paradigm for EUS

The introduction of the EVS has the potential to create a new standard for EUS delivery, aligning it more closely with common procedures like EGD and colonoscopy. This shift promises several key benefits:

Conclusion

The EVS represents a significant advancement in making endoscopic ultrasound more accessible, efficient, and profitable in the ASC setting. By addressing the traditional barriers to EUS adoption, this innovative technology opens new possibilities for gastroenterologists, ASCs, and patients alike. As demonstrated in the case study, implementing EVS can lead to practice growth, increased ASC profitability, and improved patient care.  Furthermore, with Echo-Endoscopy the practice used ultrasound with a standard EGD to drive more clinical results and increase volume.

The future of EUS lies in its broader adoption in outpatient settings, aligning with the ongoing shift towards value-based care. The EVS is at the forefront of this transformation, promising to revolutionize the delivery of advanced endoscopic services in gastroenterology.

Further Information:

 

References:

1Procedure price lookup for outpatient services. Procedure Price Lookup for Outpatient Services. Accessed September 25, 2024. https://www.medicare.gov/procedure-price-lookup/cost/43259/.