31 Panel Discussion - Weinreb (Moderator)

Targeted Biopsies and Referral Streams

I just did wanna make one point about the targeted biopsies and who does them.

I do think we should, on our slides, always give the option for urologist or radiologist driven practice for biopsy targeting.

Maybe it's a Boston thing, but I think it happens elsewhere as well.

Community urologists, as we've discussed earlier, may not have the resources to do these targeted biopsies in their offices today.

So they're anxious to have their patients avail of this opportunity as much as possible.

But I know from having talked to many of the people in the northeast area, they're reluctant to refer to another urologist to have a biopsy performed.

There's an ownership thing, there's a relationship between a urologist and his or her patient.

So I think being able to refer directly to a radiologist for a radiologist to perform a biopsy just like we do in every other organ in the body, and then have the patient referred back to their own primary urologist, is a very important referral stream that shouldn't be neglected.

Yep. I agree.

Billing for 3D Processing in MR Ultrasound Fusion

There's a question, this is from the folks not here is 3D processing for MR ultrasound fusion billable 3D

Yes. Yes. 3D it's the same 3D processing code for CT as I understand it at right.

Yeah. So there is a CPT code correct for it.

That doesn't mean you're gonna get paid, so you're allowed to bill for it.

No guarantee you'll get paid.

That's a local payer decision whether or not they'll pay you.

What is important is to make sure that in your report there is a specific paragraph that describes the processing that goes on because that will be part of potential for actual billing and reimbursement.

And 3D with volumetric component of the contouring certainly is a true 3D post-processing that requires separate workstation and separate hands-on. Yeah.

Now, keep in mind at Hopkins where Kasha is from, they bill for 3D for every exam, every CT scan,

If it is requested by the referring service.

So we use 3D as a modifier, and indeed there is reimbursement for it. Yeah.

And so we actually generate a separate report.

The important thing is if you're going to generate a separate report for the 3D billing code that the date of the exam is the date of that report, not the date that you generate the report.

Yeah. And also, I should mention, Masson, I were talking before to some extent, prostate MR with 3D Pro volumetric or post-processing is flying a little bit below the radar screen now in most places because there just hasn't been a lot done.

So it probably hasn't caught the attention yet of CMS or the local payers.

So as it grows, they may want to have some kind of justification about why they're getting these charges, why we're charging for something.

We are probably gonna have to somehow or other show that this is necessary.

So this is something I think that's going to be evolving.

Reimbursement for Targeted Biopsies

Go ahead.

Yeah. Had just a couple questions.

And the billing thing, Dr. Ani actually, which you guys were just talking about for the reimbursement, when you do the targeted biopsy, I mean, is that all you're truly doing is the targeted biopsy, just someone had mentioned earlier, but also the general quadrant biopsy like the that the urologist does.

So do you just do the four or five cores of the targeted lesion, and is there a reimbursement problem with that?

So I think if I heard all of the question, I think I lost it a little bit in the middle, was are we just doing targeted biopsies and not the systematic one?

And then do we get reimbursed for that? Is that right? Yes.

Yes. Okay. So the question, yes, we are only doing targets.

So we've got four targets per patient on average in our paper that's going in radiology next month or so.

And we do get reimbursed for that. Yes.

Handling Referrals from Non-Urologists

And then just second question is, a couple of you mentioned the last session about the referrals coming from non neurologist, but it's kinda left.

And I know colleagues that have that.

I'm just curious how you're handling that.

I didn't really hear how you're how you're handling the patient.

Like say from the internist that has patient with an elevated PSA, and so they order a MRI

How we're handling them any differently than any other patient?

Well, I mean, are you going ahead, are you doing the study?

Are you doing the MR MRI with the, so,

Yes. I had made that comment in the prior session and in the last year or so, I think we are definitely seeing some of these referrals coming in from primary care physicians.

And we are doing the MRI.

I think that this along the theme of communication and collaboration when, I guess the only thing that's really doing differently is that at the time of interpreting the exam, I'm more kind of proactively calling 'em up and discussing with them is they're not gonna necessarily know what the do with a report or the interpretation kind of, whereas our urologist, we have a system and a workflow in place, and they know exactly what to do with the primary care physician.

I'll call and kind of advise 'em a little bit, give them more input as to what their next step would be.

But typically it's, I mean, it'll be referred to a urologist at the next point.

I think it's, at least at our center, I think it's been more just their expect or their experience that the first thing that urologists where we are do off the bat be prostate mri, they're kind of appreciating that I think it was our local management pattern.

But yes, we do do them.

And I just tend, I'll tend to call up the refer afterwards and discuss it with them.

MRI Uptake in Australia and Urologist Interpretation of MRIs

Hi, Nick Brook is my name.

I'm a urologist from Australia.

There's been a massive uptake of MRI in Australia to the point now where I think most academic urologists and also others will be doing MRI before.

Is the government paying yet? Sorry?

Is the government paying? Not yet. No.

No, but the cost does vary. It's about $450 where I am.

$750 in Sydney. Yeah.

Remember for breast mr it took them many years to

So we're getting a huge number of MRIs done.

We're getting a huge number of reports.

There's been a lot of noise from urologists about learning how to read MRIs ourselves.

So my question really is how much can we truly read ourselves?

If we get the scans and we get the report, can we sort of hold them up and agree or disagree with what you've said?

Can we get the raw data?

I mean, is it like say a CT scan looking at hansfield units?

If you've got the raw data, you can measure it yourself.

How much of that is really practical for a urologist to learn how to read it?

Experience at Hopkins

So I'll speak to the experience we have at Hopkins.

We work very closely with our urology team, and they obviously do learn the more conferences and one-on-one interactions with pathology correlation we do, the more they understand the multiple parameters and they already talk to the diffusion the restriction, they start understanding this concept.

So I do believe that urologists are able to conceptualize what we are talking about.

However, I would, and they do understand the limitation of the comprehensive assessment of the prostate gland.

So I believe that education of urologists is very important so they can understand and rely on our reports better.

And also so they do understand their limitation interpretation.

So it is a challenging modality enough for us radiologists who deal with imaging throughout our years of training and practices for over decades.

And as you could see still, we challenge ourself in many difficult cases.

And so I believe what you mentioned that perhaps every surgeon looks at NA renal mass that needs to be resected and all surgical specialists look at all the masses that go for management and oncologists look at the tumors.

So this is a common practice to have a second eye sort of pair reviewing in cases of their own patients.

But I do believe that with education comes understanding of limitations.

So I don't think urologists will or should be evaluating prostates to the comprehensive sort of extent that we are accountable For.

Recognizing Salient Features

So my urologist said the same thing.

He says he wants all of his fellows to learn to read MRI at first, you know, I was nervous 'cause I'm like that's my job.

But I think what he means isn't to generate a final interpretation, but to be able to recognize the salient features.

And to that end, when I process a case like I was showing you all earlier, when I find that image of the 3D and the T two and the DWI and the A DC and the DCE, I take a snapshot of those six images and I send that to PAX as secondary capture.

And that's useful for me. 'cause I can't remember what I thought five minutes ago, much less a year ago.

So when the patients come back for a targeted biopsy or surgery, that reminds me where the thing was.

But also when the urologist or when the radiation oncologist wants to pull up what was Dan thinking?

They can look on the screen capture, see, oh, it's the T two series image number 32, here's what Dan was circling.

I can see it here. We can use the DICOM colloquial tool to pull up the DWI or the profusion map and scroll through that and get a sense of here's the T two abnormality that Dan circled.

And here's the other things.

So it's helpful when we have the screen captures as a guide sort of as like the training wheels.

I don't know that they'll ever come off, but I think that learning to recognize the features using what we provide as a guide is going to be imperative for using this technology to manage our patients. So I,

Different Perspective on Urologist Learning

Let me give a little bit different perspective on it.

You know, I think people who are physicians are generally pretty smart people and most of us could probably learn anything.

So is there any reason why urologists can't learn to in to look at an MRI and figure out what's going on?

Of course not.

And frankly, if you are taking care of a patient, MRI in this regard is no different than anything else.

Would you operate on a patient without understanding what the CT is showing or without understanding what any study is showing.

So clearly urologists, if they're treating the patient, they have to understand what they're looking at on the MR scan.

The way MR is a little bit different than perhaps a CT scan is that there's a lot more images and a lot more data and a lot more artifacts.

And frankly, it just takes a lot more expertise to sort this stuff out.

And if you've been sitting here the last couple of days, again, we're showing you stuff, we're showing you the best examples to teach you, but frankly, all the cases don't look like this.

A lot of them are much tougher than this to interpret.

So urologists should learn how to read these things, but actually supervising the scan reporting them is probably someplace they shouldn't go.

In the United States, we do have self-referral regulations and there are ways around it.

The government's looking very closely at this now though, and I suspect that going forward they're going to make it much more difficult for people to, if they do own MR scanners or have a share of an MR scanner to send the cases there and then interpret the exam and then say, oh, I interpreted the exam, now I'm gonna do surgery on this patient.

I think there are gonna be safeguards to prevent that type of thing going into the future.

Thanks very much. So again, I think it's a the team concept is really in, if you look at it from the perspective of what's best for the patient, what's best for the patient is that we all do what we do best and then work together in the patient's interest.

And if you wanna put the fear into your heart, just Andy wrote a really nice article on the 10 Pitfalls of Prostate Mar that has helped me more than once.

Convincing Urologists for Pre-Operative MRI Before Robotic Surgery

We have a couple of other questions from outside.

Well, let's see.

How do you convince the urologist for pre-op MRI before robotic surgery? Anybody wanna

Show them my article?

Take that one. Well, again, we emphasize the teamwork.

They need to see the examples and examples of cases where the cancer is in challenging locations, those epical cancers extending along the sphincter.

And you know, it seeing the tumor and understanding how wide they need to go with the concept that they want to preserve map sphincter as needed for maintenance of continence, and then maintain the oncological optimization in terms of cancer control.

Once they see examples, then they will understand. So

Australian Practice on Pre-Operative MRI

Maybe, can I ask, since we have, so we have a friend from down under a urologist or any of the other urologists, are you still here?

Maybe you can tell us what you know, what would what's changed in Australia and why, what would it take to send patients for prostate MRI prior to robotic surgery?

Again, in Adelaide where I come from, it's absolutely routine.

You're way down under,

Yeah.

No one would undertake surgery without an MRI.

Although I know there are some sort of differences of opinions sort of worldwide.

You know, I don't really know exactly what the change was.

I think it was the detailed anatomy the perceived importance of nerve sparing.

There's been a real drive, but we don't do CT at all anymore.

Preoperatively, there's some concern about lymph node assessment prior, of course.

So we do ask for that to be included in the reports prior.

But yeah, we wouldn't dream of performing surgery without an MR mri.

It's just been the last two years there's been a sea change.

Do you get 3D models or maps or anything like that? Or is it just a

Standard No. D no, I

mean, we have a multidisciplinary yeah, neurological oncology meeting and we discuss them there pre-op and then post-op when we've got the path and we have the pictures sort of alongside the gross or the yeah, the gross macro path.

So everything's very reviewed on a regular basis, but not 3D now.

Yeah, I think that 3D can potentially help in the US 'cause I know my surgeons like to have that a lot, and we do that.

We haven't been billing for that.

Now I've realized maybe I'm leaving some money on the table here, so I've,

my computer scientists are generating those maps, so that could help too.

Closing Remarks

Okay. So I think we're unless there are any other questions, I think we've come to the end of the road.

So I want to thank the speakers because everybody took a lot of time, not only from their busy schedule to come here and present these great talks, but there was a fair amount of preparation involved.

When we put this conference together, we sort of ran around different ideas and sort of put this conference together as a group.

And I don't know.

I'm real happy the way it turned out.

So thanks to everybody.

I think everybody, we all learned a lot from each other and also from you all.

Thanks. Thank.