How to Set Up a Successful Motility Lab

Gastrointestinal (GI) motility disorders account for nearly one-half of outpatient gastroenterology visits, and motility tests are widely utilized to assess a multitude of chronic GI complaints.1Peery A.F. Crockett S.D. Murphy C.C. et al.Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018.Gastroenterology. 2019; 156: 254-272 e11Abstract Full Text Full Text PDF PubMed Scopus (390) Google Scholar Fortunately, advancements in motility technologies and diagnostic concepts have enhanced the ability to characterize physiology and function across this prevalent patient population. Along the same lines, there is a growing trend of motility subspecialization among gastroenterologists and surgeons. In response to market demands, motility labs are increasingly initiated and grown. The prior landscape with scant motility labs scattered across the nation has dramatically shifted, and nowadays, motility labs are accessible across private and university-based settings, hospital and ambulatory surgical centers, and small and large provider groups. In 2019, >120 motility labs in North America, most affiliated with academic centers, were included in the American Neurogastroenterology Motility Society registry of GI motility laboratories. Distinct from the more familiar clinic or endoscopic procedure setting, motility labs require unique considerations within the following domains (the 4 Ps):•Physical: space, size, location•Process: scheduling, testing, pretesting and post-testing considerations•People: personnel, roles, responsibilities, training•Price: economic structure In the basic sense, a motility lab is a physical space equipped for motility diagnostic testing. A well-designed motility lab is patient centric, providing comfort and protecting privacy, while concurrently promoting workflow efficiency and patient safety. Location of the lab is crucial. Proximity to endoscopy suite provides ease for combined endoscopic–physiology lab procedures such as endoscopic placement of manometry catheters (esophageal, colonic, antroduodenal) and wireless pH capsules as well as functional luminal imaging planimetry evaluation of the GI tract. Proximity to the provider offices or clinic space offers easier access for troubleshooting. Proximity to the catheter cleaning facility optimizes efficiency by lowering the turnaround time of catheters. The optimal size of the GI motility suite depends on the initial desired capacity, as well as the projected growth of the facility. We recommend a minimal size of 400 square feet (size of a small hotel suite) with wall separation for 1 private room to perform esophageal and/or anorectal procedures. Such a room would allow for performance of approximately 25–40 procedures weekly. Noninvasive tests, such as breath tests, can be performed in semiprivate spaces separated by curtains. Basic requirements in each procedure room include a reclineable bed to adjust patient position; a mobile desk; a chair with adjustable height; a sink with running water; cabinets stocked with basins, towels, gauze, and other supplies; a sharps and biohazard disposal bin; waste and soiled linen bins; and suction and oxygen capability, in addition to the testing equipment. An emergency call button may be installed if patients will be left in the room on their own. A patient restroom should be easily accessible either within or near the lab. Throughout the planning phase and before finalizing the layout for the physical lab space and patient care process, it is prudent to ensure that the plans set forth are in compliance with standards set by state and federal regulatory authorities. The requirements may vary depending on the state and the accreditation organization, such as the Joint Commission. Facilitating comprehensive patient care from start to finish requires optimization of preprocedural, intraprocedural, and postprocedural processes. The primary constituents of the process include administrative tasks, direct patient care, equipment maintenance, and study interpretation. Building a comprehensive and logical schedule template is pivotal to running an efficient lab. Procedure blocks should account for the time duration required from the patient check-in process, intraprocedural components, and room and catheter turnaround time, in addition to an extra time allowance for add-on protocols (eg, rumination protocol), troubleshooting, and research data collection. The template must take into account the volume demand of each study type and the availability of personnel, catheters, and test equipment. Further, the template should incorporate lunch and break times for the lab staff and unscheduled time slots for potential urgent add-on tests. An example of a weekly schedule template for a combined upper–lower GI procedure room is shown in Figure 1. In this template, esophageal studies are conducted earlier in the day owing to patient NPO status and the potential need for more extensive cleaning after lower GI studies. Same-day add-on slots are allotted a few days a week (eg, for urgent inpatient cases or to accommodate clinic patients traveling a long distance). Additionally, ambulatory reflux studies are scheduled only during the earlier half of the week to allow patients to return, after a 24-hour monitoring, on a weekday for catheter removal and return of the recorder. A few other considerations to optimize work flow between a tight schedule and many moving pieces include supervising physician availability (a lab director or an on-call physician daily for assistance in trouble shooting) and nurse/technician flexibility in performing various motility procedures. If there are openings in a weekly schedule, the motility lab space can be used for other clinical, research, and/or administrative purposes. In an office motility billing environment, the motility lab space can be used for general office consultations. In a hospital or ambulatory surgical center environment, the lab space may be conducive to alternative GI evaluations or treatments such as infusions, hemorrhoid procedures, unsedated endoscopic procedures (eg, transnasal upper endoscopy, flexible sigmoidoscopy, anoscopy), or gastrostomy tube exchange. Patient instructions for the upcoming motility procedure need to be accurate, comprehensive, and procedure specific. Procedure-specific instructions detail information about NPO status, sedation for procedure, whether a driver will be required, medication considerations, and, for lower gut motility testing, bowel preparation. Medication considerations include pharmacologics that modulate physiology (ie, acid suppression, opiates, anticholinergics) as well as medications that increase procedure risk (ie, blood thinners). Ideally, patient instructions are conveyed in person or over the phone to allow patients to ask questions, rather than solely provided through paper or digital handouts. Patient information on motility studies can be found on the American Neurogastroenterology and Motility Society website (www.motilitysociety.org) that can be further tailored to local practice. Patient instructions upon discharge should include a contact number for communication of possible procedure-related symptoms and equipment malfunctioning, as well as clear instructions for when to return equipment such that the test equipment is processed and ready for the next scheduled patient. Direct patient care during the motility session includes procedure consent, preprocedure questionnaires, and procedure time, including equipment calibration. The personnel performing the motility test can range from a trained technician, nurse, or provider. After the procedure, processes need to be in place for efficient room and catheter turnaround. Additionally, motility data need to be prepared for interpretation, which often includes describing the study indication, defining test frames and landmarks, removing artifacts, and inserting notable events and diary recordings, if applicable. Once the study file is interpreted by a trained provider, the final report should be forwarded to the referring provider and patient, and the procedure and interpretation should be billed. Various permutations of personnel roles and responsibilities are possible in a motility lab. In a moderate volume fully equipped motility lab, medical assistants often share the majority of administrative tasks. Direct patient care is generally provided by a trained motility registered nurse, although in many described models a trained motility technician or the motility provider provide the direct patient care. Regardless, all study interpretations are performed by a trained provider through review of the electronic tracings and data. Currently, there is an initiative to optimize motility training and ensure that providers interpreting motility studies possess the technical, cognitive, and integrative skills essential for safe and effective unsupervised practice.2Yadlapati R. Keswani R.N. Pandolfino J.E. Competency based medical education in gastrointestinal motility.Neurogastroenterol Motil. 2016; 28: 1460-1464Crossref PubMed Scopus (12) Google Scholar,3Rao S.S. Parkman H.P. Advanced training in neurogastroenterology and gastrointestinal motility.Gastroenterology. 2015; 148: 881-885Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar Learning curves for the interpretation of esophageal manometry are known to vary, and personalized competency-based motility training platforms have been developed that seem to be effective for improving interpretative skills across gastroenterology trainees. As such, there is growing interest to standardize motility curricula for fellowship programs, and develop certification and credentialing processes for providers interpreting motility studies.4Gyawali C.P. Savarino E. Lazarescu A. et al.Curriculum for neurogastroenterology and motility training: a report from the joint ANMS-ESNM task force.Neurogastroenterol Motil. 2018; 30e13341Crossref PubMed Scopus (6) Google Scholar At present, societies including the American Neurogastroenterology and Motility Society, American Foregut Society, American College of Gastroenterology, and American Gastroenterological Association offer hands-on workshops on study interpretation. Personnel performing the procedure (motility nurses and technicians) typically train through an apprenticeship model of observation and hands-on experiences, often based on minimum case volume, overseen by an experienced supervisor. Equipment representatives are often available to provide guidance and troubleshooting tips. More standardized training is offered through workshops hosted by equipment manufacturers as well as during conferences held by organizations such as the American Neurogastroenterology and Motility Society. A decision to either begin the development of a motility lab or increase the capabilities of an existing lab should include a thorough economic assessment. General considerations such as a strengths, weaknesses, opportunities, and threats evaluation and a return on investment analysis are adequate starting points. However, physicians involved in this field are often not trained to pursue comprehensive financial appraisals and external assistance is often valuable. An economic framework is beneficial to organize factors leading to overall profit or loss in the lab, and then any change in the function of a lab can be applied to this structure. We recommend a general approach here:1.Preparationa.Define the test algorithm: test billing locations, if technician/nurse is performing test alone or using physician time, time committed to each procedure, how catheters are reprocessed and by whom2.Cost analysisa.Direct costs: personnel salaries and benefits, total equipment cost while understanding manufacture warranties, reprocessing cost, supplies, use of spaceb.Indirect costs: equipment depreciation3.Reimbursement analysisa.Optimization of reimbursement for each testb.Estimate procedures done per year based on referral patterns4.Final calculationa.Profit versus loss for each procedureb.Profit versus loss for entire lab Reimbursement for a motility lab can vary significantly by factors such as geography and practice location. There are few reference materials in the literature to guide the motility practitioner in this topic. Most recently an American Neurogastroenterology and Motility Society commissioned report provided a billing and coding update on esophageal function testing in 2018.5Khan A. Massey B. Rao S. et al.Esophageal function testing: Billing and coding update.Neurogastroenterol Motil. 2018; 30Crossref Scopus (3) Google Scholar The authors detailed methods to optimize reimbursement in the current billing environment and provided suggestions for future esophageal coding changes if deemed appropriate by GI societies. For instance, if motility testing and billing is done in a physician’s office, rather than a hospital location, for many relevant procedures the physician reimbursement can increase by a factor of 5-fold or more, because the physician is billing for both the professional and technical components, despite unchanged work revenue value units.5Khan A. Massey B. Rao S. et al.Esophageal function testing: Billing and coding update.Neurogastroenterol Motil. 2018; 30Crossref Scopus (3) Google Scholar This can alter the time commitment the physician can justify surrounding the particular motility procedure. However, the initial cost of equipment may be prohibitive to a physician practice and the practice may resort to setting up the motility testing in a hospital setting to avoid the cost of acquisition. A physician involved in leadership of a motility lab should have an understanding regarding optimizing reimbursement for the offered procedures. We find that even experienced billers and coders for gastroenterologists may not be familiar with the nuances of coding in this discipline. For instance, when performing esophageal manometry with an assessment of bolus transit (Current Procedural Terminology [CPT] codes 91010 and 91037) and an additional catheter-based test, such as an impedance pH catheter (CPT codes 91034 or 91038) is placed on the same day, separating the visit into 2 clinical encounters to allow for an interpretation session for each may augment the value of the work performed and avoid duplicative coding that will not be approved.5Khan A. Massey B. Rao S. et al.Esophageal function testing: Billing and coding update.Neurogastroenterol Motil. 2018; 30Crossref Scopus (3) Google Scholar Another example is the need to use modifier 59 when conducting pelvic floor biofeedback therapy (CPT codes 90901 or the new codes for 2020 of 90912 and 90912) and anorectal manometry (CPT code 91122) on the same day, because the Centers for Medicare and Medicaid Services considers these procedures mutually exclusive owing to the use of manometry catheter in both anorectal manometry and biofeedback training. Table 1 lists the relevant active CPT codes for 2020 published yearly by the American Medical Association and includes considerations and recommendations for the unique procedures a motility lab can provide.Table 1Relevant Active CPT Codes for 2020 Published Yearly by the American Medical AssociationCPT code for 2020Tests and DefinitionsClinical Applications and ConsiderationsPhysician Practice Fee CategoryModifier for FeePhysician Work RVUsawww.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F, CY 2020 PFS Final Rule Addenda2020 Medicare National Average Reimbursement Allowableawww.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F, CY 2020 PFS Final Rule Addenda2020 APC Payment Rate To Hospital (Otherwise N/A)bwww.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1717-FC, 2020 NFRM OPPS Addenda2020 Payment Rate to ASC (Otherwise N/A)Cwww.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-Notices-Items/CMS-1717-FC, Addendum AA, BB, DD1, DD2 and EE)ESOPHAGEAL FUNCTION TESTINGEsophageal manometry 91010Esophageal motility (manometric study of the esophagus and/or gastro-esophageal junction) study with interpretation and reportEither conventional or high-resolutionGlobal1.28$205.71$485.55Professional261.28$68.21TechnicalTC$137.50 91013With stimulation or perfusion (e.g., stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedure)Stimulation during esophageal manometry; Combine with 91010; Unclear if can be used for a meal given with standard manometryGlobal0.18$26.35Professional260.18$9.74TechnicalTC$16.60Transnasal pH monitoring 91034Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretationImpedance-pH testing can bill for this or 91038Global0.97$195.25$485.55Professional260.97$51.97TechnicalTC$143.28Wireless pH ambulatory reflux monitoring 91035Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretationUse modifier 59 for endoscopy if no other indication or intervention performed during endoscopy placementGlobal1.59$494.79$485.55$245.37Professional261.59$85.53TechnicalTC$409.26Esophageal impedance monitoring 91037Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretationEsophageal impedance up to 1 hour; Can be combined with 91010 as assessment of bolus transitGlobal0.97$169.98$253.07Professional260.97$51.61TechnicalTC$118.38 91038Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; prolonged (>1 hour, up to 24 hours)Transnasal impedance monitoring greater than 1 hour and up to 24 hours; Impedance-pH testing can bill for this or 91034Global1.10$449.32$485.55Professional261.10$58.47TechnicalTC$390.85Functional Lumen Imaging Probe (FLIP) 91040Esophageal balloon distension study, diagnostic, with provocation when performedFLIP testing of the esophagusGlobal0.97$519.70$485.55Professional260.97$52.69TechnicalTC$467.00COLON AND ANORECTAL FUNCTION TESTINGBiofeedback training 90901Biofeedback training by any modalityGeneral biofeedback code0.41$41.50 90912 (added for 2020)Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patientBiofeedback training of the pelvic floor first 15 minutes0.90$81.92 90913 (added for 2020)Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately)Biofeedback training of the pelvic floor each additional 15 minutes; List separately with first biofeedback code0.50$33.20Colonic manometry 91117Colon motility (manometric) study, minimum 6 hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and reportMust have recording for at least 6 hours2.45$234.87Anorectal manometry 91120Rectal sensation, tone, and compliance test (i.e., response to graded balloon distention)Typically added to anorectal manometry code if sufficient sensation and compliance data collectedGlobal0.97$497.68$138.33Professional260.97$50.89TechnicalTC$446.79 91122Anorectal manometryAnorectal manometry, either conventional, high-resolution, or 3DGlobal1.77$257.32$234.87Professional261.77$92.03TechnicalTC$165.29Nerve conduction analysis 95907-95913Nerve conduction studiesOften relevant to colorectal motility assessments, use specific code for volume performedGlobal1.00-3.56$97.80-310.37$138.33-$485.55Professional261.00-3.56$55.58-194.53TechnicalTC$42.23-115.85Transrectal ultrasound 76872Ultrasound, transrectalTransrectal ultrasound examinationGlobal0.69$159.88$112.07$56.63Professional260.69$34.29TechnicalTC$125.59OTHER MOTILITY AND FUNCTION TESTINGAntroduodenal manometry 91022Duodenal motility (manometric) studyGlobal1.44$172.15$485.55Professional261.44$76.51TechnicalTC$95.64Breath testing 91065Breath hydrogen or methane test (e.g., for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit)Global0.20$81.56$138.33Professional260.20$10.47TechnicalTC$71.10Wireless motility capsule 91112Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and reportPatient can have recorder for up to 5 daysGlobal2.10$1,479.32$785.83Professional262.10$111.52TechnicalTC$1,367.81Electrogastrography 91132Electrogastrography, diagnostic, transcutaneousElectrogastrography diagnostic testingGlobal0.52$330.58$138.33Professional260.52$27.79TechnicalTC$302.80 91133Electrogastrography, diagnostic, transcutaneous; with provocative testingElectrogastrography diagnostic and provocative testingGlobal0.66$354.40$109.02Professional260.66$35.01TechnicalTC$319.40Sphincter of oddi manometry 43263Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of OddiERCP with diagnostic measurement of sphincter of Oddi6.50$2,998.75$1,306.14Translumbar repetitive magnetic stimulation 97032Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutesUse for translumbar repetitive magnetic stimulation0.25$15.163D manometry studies 763763D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; not requiring image post-processing on an independent workstationCan attempt to add to manometry studies (91010 or 91122) using 3D technologyGlobal0.20$23.46Professional260.20$10.11TechnicalTC$13.35NOTE. Published yearly by the American Medical Association with considerations and recommendations for the unique procedures a motility lab can provide. (Reimbursement and Payment Rates based on accessing the Centers for Medicare and Medicaid Services [CMS] tools as of December 4, 2019, for 2020 (if correction notice sent by CMS after this date this could change values).a www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F, CY 2020 PFS Final Rule Addendab www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1717-FC, 2020 NFRM OPPS Addendac www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-Notices-Items/CMS-1717-FC, Addendum AA, BB, DD1, DD2 and EE) Open table in a new tab NOTE. Published yearly by the American Medical Association with considerations and recommendations for the unique procedures a motility lab can provide. (Reimbursement and Payment Rates based on accessing the Centers for Medicare and Medicaid Services [CMS] tools as of December 4, 2019, for 2020 (if correction notice sent by CMS after this date this could change values). The decision to offer particular motility diagnostics, and therefore invest in the relevant equipment, is tailored to the needs and volume of the health care organization. For instance, an institution that offers foregut surgeries would benefit from esophageal motility and reflux testing capabilities in the motility lab. In contrast, an institution providing pelvic floor biofeedback therapy would benefit from anorectal motility testing capability with trained personnel. Cost–benefit considerations also drive the decision to include specific diagnostic equipment. For example, adding on high-resolution anorectal manometry to an existing high-resolution esophageal manometry system might make financial sense when purchased from a single manufacturer. One motility room equipped to perform esophageal and anorectal manometry inclusive of equipment, 2 catheters, room supplies/furniture, and computer (not including costs related to space and staff compensation) will cost roughly $300,000. As the paradigms of GI motility evolve, remarkable opportunities are available to those interested in initiating or expanding a motility practice. A practical approach is paramount, and acquisition of novel equipment should only come after careful consideration of the broader institutional financial capability and health care needs. As cross-disciplinary collaboration involving surgery, pulmonology, radiology, otolaryngology, psychology, and nutrition is becoming increasingly emphasized in the field of GI motility, communication across disciplines is essential to our understanding of downstream revenue as well as clinical demands. When expansion of a GI motility lab is implemented, a requisite priority should be to provide accurate and consistent care. Standardized protocols for motility testing and data interpretation across motility centers are still needed. Training workshops should ideally be sponsored or approved by authorities in GI motility, and further development of quality indicators and competency measures are critical. Looking ahead, with the continual advancements and modernization of GI motility labs, relevant physician leaders must be willing to frequently embrace novel technology, but also be conscious that a motility lab should have the capacity to thrive in a value-based health care system that balances cost spending with favorable patient outcome. Although GI motility labs must always find an appropriate place in a local health care environment, the doors are indeed open for unprecedented patient care and widespread research collaborations that will undoubtedly further improve our knowledge in the pathophysiology and treatment in GI motility disorders.