The Laryngoscope

C 2015 The American Laryngological,

V
Rhinological and Otological Society, Inc.

A Cost and Time Analysis of Laryngology Procedures In the

Endoscopy Suite Versus the Operating Room

Alexander T. Hillel, MD; Matthew C. Ochsner, BS; Michael M. Johns III, MD; Adam M. Klein, MD, FACS

Objectives/Hypothesis: To assess the costs, charges, reimbursement, and efficiency of performing awake laryngology
procedures in an endoscopy suite (ES) compared with like procedures performed in the operating room (OR).
Study Design: Retrospective review of billing records.
Methods: Cost, charges, and reimbursements for the hospital, surgeon, and anesthesiologist were compared between ES
injection laryngoplasty and laser excision procedures and matched case controls in the OR. Time spent in 1) the preoperative
unit, 2) the operating or endoscopy suite, and 3) recovery unit were compared between OR and ES procedures.
Results: Hospital expenses were significantly less for ES procedures when compared to OR procedures. Reimbursement
was similar for ES and OR injection laryngoplasty, though greater for OR laser excisions. Net balance (reimbursement–
expenses) was greater for ES procedures. A predictive model of payer costs over a 3-year period showed similar costs for ES
and OR laser procedures and reduced costs for ES compared to OR injection laryngoplasty. Times spent preoperatively and
the procedure were significantly less for ES procedures.
Conclusions: For individual laryngology procedures, the ES reduces time and costs compared to the OR, increasing oto-
laryngologist and hospital efficiency. This reveals cost and time savings of ES injection laryngoplasty, which occurs at a simi-
lar frequency as OR injection laryngoplasty. Given the increased frequency for ES laser procedures, total costs are similar for
ES and OR laser excision of papilloma, which usually require repeated procedures. When regulated office space is unavailable,
endoscopy rooms represent an alternative setting for unsedated laryngology procedures.
Key Words: Office-based procedures, reimbursement analysis, injection laryngoplasty, vocal fold paralysis, laryngeal
papilloma, potassium titanyl phosphate laser procedures.
Level of Evidence: NA
Laryngoscope, 126:1385–1389, 2016

INTRODUCTION with laryngoscope placement, including injury to teeth,

As in the preanesthetic era, unsedated “office-
based” laryngology procedures have once again gained
favor in recent years. This swing of the pendulum is due
to numerous factors, including the avoidance of general
anesthesia, leading to decreased procedure times and
more efficient use of surgeon time and facility space.
Unsedated patients benefit by avoiding the risks and
recovery from anesthesia, as well as the risks associated
From the Department of Otolaryngology–Head & Neck Surgery
(A.T.H.), Johns Hopkins University School of Medicine, Baltimore, Mary-
land; Emory University School of Medicine (M.C.O.), Atlanta, Georgia;
Emory Voice Center, Department of Otolaryngology–Head & Neck Sur-
gery (M.M.J., A.M.K.), Emory University School of Medicine, Atlanta, Geor-
gia, U.S.A.
Editor’s Note: This Manuscript was accepted for publication
August 13, 2015.
Alexander T. Hillel was responsible for the study design, data
acquisition, data interpretation and analysis, and manuscript prepara-
tion. Matthew C. Ochsner was responsible for data acquisition, data
interpretation and analysis, and manuscript preparation. Michael M.
Johns was responsible for the study design and data analysis. Adam M.
Klein was responsible for the study conception and design, data analysis,
and manuscript preparation.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Adam M. Klein, MD, Emory Voice Center,
Department of Otolaryngology, Emory University School of Medicine,
MOT–Suite 9-4400, 550 Peachtree Street, Atlanta, GA 30308. E-mail:
aklein4@emory.edu
DOI: 10.1002/lary.25653
sore throat, tongue discomfort, and/or dysgeusia.1–3
Office-based procedures have a favorable cost com-
parison with their operating room (OR) counterparts.
Rees et al. analyzed the difference between laser proce-
dures performed in the office versus the OR, demon-
strating a cost savings of greater than $5,000 for every
laser procedure performed in the office versus the OR.4
Bove et al. showed a potential cost savings of over
$10,000 for awake office-based injection laryngoplasty
compared with OR injection laryngoplasty.5 Although
these results are enticing from a cost-savings perspec-
tive, surgeon reimbursement rates for the office-based
procedures do not reliably cover the associated clinic
costs of injection material, laser fiber, equipment, and
clinical staff.3,5 Kuo and Halum’s study highlights the
disconnect between optimizing patient safety and effi-
cient care while reducing healthcare costs for payers,
but at the surgeon’s expense.3 This disincentive pushes
physicians back to the OR setting.3
There are options to office-based procedures that
reduce healthcare costs and maintain patient safety.
Converting nonfacility clinic space to facility-based space
may make financial sense and allow for an additional
facility fee to cover the incidental costs; however, this
may only be feasible in a small percentage of otolaryn-
gology practices. Another alternative is to perform unse-
dated injection laryngoplasty and laser treatment of

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1385
Fig. 1. Intraprocedure endoscopic image of endoscopy suite injection laryngoplasty via a transoral approach (A) compared with intraopera-
tive endoscopic image of operating room injection laryngoplasty through suspension microlaryngoscopy (B).

vocal fold lesions in a hospital-based facility such as an
endoscopy suite (ES). Even though the hospital ES is
designed for gastroenterology and interventional pulmo-
nary procedures with sedation, it may also allow for
unsedated laryngology procedures while avoiding the
financial losses associated with office-based procedures
in unregulated otolaryngology offices. We hypothesize
that the ES can be a cost-saving, yet revenue-producing,
location to perform awake laryngology procedures, and
at the same time provide better time efficiency than sim-
ilar procedures performed in the OR.
MATERIALS AND METHODS
This study was approved by the Emory University Institu-
tional Review Board. Initially, a pool of 784 patients was gener-
ated by identifying all patients who underwent awake
potassium titanyl phosphate (KTP) laser (ESLaser) excision of
papillomas in a hospital ES (n 5 366) and asleep KTP laser
(ORLaser) excision of papillomas in the OR (n 5 68), as well as
awake injection laryngoplasty (ESIL) in a hospital ES (n 5 328)
and asleep injection laryngoplasty (ORIL) in the OR (n 5 22)
from May 2011 through May 2014. Figure 1 shows images from
ESIL and ORIL, whereas Figure 2 demonstrates ESLaser and
ORLaser. Patients were identified with Current Procedural Ter-
minology (CPT) codes: 31571 for injection laryngoplasty and
31541 for laser excision. The CPT code used for unsedated
endoscopy procedures was the unlisted code, 31599, with subco-
des Z1498 (laser) and Z1471 (injection). OR cases were limited
to single procedure codes to accurately compare with ES cases,
which lowered the number of eligible ORIL cases to 16. In the
other three groups, 16 patients were selected from the larger
pool, with no patients under the age of 18, and the most
recently treated patients were chosen to make the financial
information as accurate as possible.
The interval frequency of laser excision of papilloma proce-
dures in the ES versus the OR was reviewed. This was done to
assess the extent of papilloma resection, which could be more
thorough in the OR and require more frequent procedures in
the ES, thus minimizing its cost savings. Interval frequency
was calculated by months between the first procedure in this
window and the final date in our study divided by the number
of procedures in this time frame.
A retrospective review of billing records provided by the
home institution billing department was performed to analyze
cost and time associated with every procedure. Cost assessment
included preoperative unit laboratory testing, intravenous

Fig. 2. Intraprocedure endoscopic image of endoscopy suite laser excision of laryngeal papilloma through the working channel of a flexible
laryngoscope (A) compared with intraoperative endoscopic image of papilloma through suspension microlaryngoscopy (B).

Laryngoscope 126: June 2016 Hillel et al.: Endoscopy Suite Laryngology Procedures
1386
fluids, drugs administered, laser fiber or tissue filler, pathology TABLE I.
charges, room charges, recovery charges, surgeon fees, and Average Costs, Charges, and Reimbursement in Endoscopy Suite
anesthesiologist fees (OR cases only). Collections were stratified and Operating Room Injection Laryngoplasty.
by hospital (including supplies, medications, and room utiliza-
tion), surgeon, and anesthesia (OR cases only). Time analysis Charges Reimbursement Costs Net Gain
(US$) (US$) (US$) (US$)
included minutes spent in 1) the preoperative unit, 2) the oper-
ating or endoscopy suite, and 3) operative time care unit for OR ES hospital $2,841 $2,052 $1,737 $315
cases and ES cases, and 4) postanesthesia time (postprocedure
OR hospital $7,403 $2,258 $2,231 $37
observation times were not recorded in the ES). Student t test
was used to estimate the difference between charges, reim- ES surgeon $1,063 $428
bursement, and time for ES and OR cases. Associations were OR surgeon $787 $360
considered statistically significant for 2-sided tests with P < .05. OR anesthesiology $789 $351
SAS 9.2 (SAS Institute, Cary, NC) was used for this analysis.
Results from the procedure interval analysis of OR-only ES 5 endoscopy suite; OR 5 operating room.
and ES-only laser excision of papilloma patients were entered
reimbursement of $2,964 (Table II). There was a signifi-
into a theoretical model to predict total payer costs over a
3-year period. Average cost for ES laser cases was added to the cant difference between surgeon charges for ORLaser
surgeon’s reimbursement and multiplied by the average number and ESLaser (P 5 .032), and the surgeon reimbursement
of cases an ES-only patient would be expected to have over a rate was greater for ESLaser when compared to
36-month period based on the average number of months ORLaser (P 5 .002). At the study site, ESLaser netted
between procedures for ES-only patients. Similarly, to calculate $502/case compared with $229/case in ORLaser.
total healthcare costs for OR laser excision, average cost for OR Laser excisions in the ES occur more frequently than
laser cases were added to the anesthesia and surgeon’s reim- in the OR. Analysis of the two groups of papilloma patients
bursement and multiplied by the average number of cases the demonstrated overlap between groups, as many patients
OR-only patients would be expected to have over a 36-month
included in the OR group also had ES cases during the
period based on the average number of months between proce-
dures for ES-only patients. study period, and vice versa. The average interval between
all cases for patients stratified by group (4.33 months OR
versus 5.36 months ES) was not different between OR (4.3
RESULTS months) and ES (5.36 months) laser excision of papilloma.
Third-party payer mix was similar between the two There was a subset of eight OR patients who only had OR
groups. Table I demonstrates the third-party payer mix. cases (8.6 months) who had an increased interval (P 5
Third-party payers were 60% managed care and 40% .037) compared with the six ES patients who only had ES
Medicare for ES procedures, and 80% managed care and cases (4.6 months) during the study period.
20% Medicare for OR procedures. Among the patients in Unsedated ES procedures increased surgeon effi-
this study, none had Medicaid. Mean total reimburse- ciency. ES procedures took less time when compared
ment for all ES procedures in this study was $2,010.00, with like OR procedures (Table III). At every procedure
whereas mean total reimbursement for OR procedures stage, preoperative, operative, and postoperative ES pro-
was $2,611.00. The mean difference in treatment setting cedures took significantly less time than OR cases. That
reimbursement was $601.00. reduced time translated to increased surgeon and hospi-
Hospital expenses were significantly less for ES tal facility efficiency for ES cases. Table IV shows that
procedures when compared to OR procedures. The mean the surgeon’s opportunity cost in the ES is $41/minute
cost of an ESIL procedure averaged $1,737 versus as compared to $10/minute in the OR.
$2,231 for ORIL (P 5 .0032). Additionally, the average Predicted total costs to payer would be less for ES
cost of an ESLaser procedure averaged $1,465 versus
injection laryngoplasty and similar for laser excision of
$2,735 for an ORLaser procedure.
papilloma. Assuming patients receive the same number
Reimbursement was similar for injections in ES
of injection laryngoplasties, total costs to payer would be
and OR. Hospital charges were significantly greater for
$2,265 in the ES and $2,942 in the OR. This difference
OR procedures for both injection laryngoplasty (P <
is primarily explained by costs associated with the
.0001) and laser excision of papilloma (P < .0001). There
was no significant difference in reimbursement in the
injection laryngoplasty groups (P 5 .339). The total reim- TABLE II.
bursement for ESIL averaged $2,052, whereas reim- Average Costs, Charges, and Reimbursement in Endoscopy Suite
and Operating Room Potassium Titanyl Phosphate Laser Excision
bursement for all ORIL procedure-related services was of Papilloma.
$2,258 (Table I). The charge for the surgeon was greater
Charges Reimbursement Costs Net Gain
for ESIL than ORIL (P < .023), whereas reimbursement (US$) (US$) (US$) (US$)
was not statistically significant between the two (P 5
.12). At the study site, the net balance for ESIL was ES hospital $2,940 $1,967 $1,465 $502
$315/case versus $37/case for ORIL. OR hospital $9,054 $2,964 $2,735 $229
Reimbursement was greater for laser excisions per- ES surgeon $1,200 $584
formed in the OR compared to the ES. There was a sig- OR surgeon $905 $363
nificant difference in reimbursement in the laser OR anesthesiology $1,354 $731
excision groups (P 5 .037). In ES laser excision of papil-
lomas, ES reimbursement was $1,967 compared to OR ES 5 endoscopy suite; OR 5 operating room.

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 TABLE III.
Time Comparison Between Unsedated Endoscopy Suite
Laryngology Cases and Like Operating Room Cases.
Endoscopy Operating
Suite (min) Room (min)
Time in preprocedure 37.1 107.4
Time of actual procedure 12.4 37.5
Time in endoscopy 20.0 69.1
suite/operating room
Time in postprocedure N/A 112.8
Total 67.1 289.3
N/A 5 not applicable.
anesthesiologist. Based on the results of average interval
between endoscopy procedures in the subset of ES-only
patients, ES patients would be expected to have an aver-
age of 7.83 endoscopic procedures, with a total health-
care cost of $16,044 over a 3-year period. Patients who
were only treated in the OR for their papilloma would
be expected to have an average of 4.18 surgeries, for a
total cost of $16,005 over the same period. Anticipated
total healthcare costs over a 3-year period for laser
treatment of papilloma and a single injection laryngo-
plasty are compared in Table IV.
DISCUSSION
Unsedated laser photoablation of laryngeal lesions
and injection laryngoplasty represent a few of the awake
procedures that patients will tolerate with appropriate
topical anesthesia. Rees et al., Bove et al., and Kuo and
Halum demonstrated overall healthcare savings for these
procedures when performed in an office setting.3–5 Kuo
and Halum, however, showed that reimbursement falls
short of covering the office-based procedural costs for dis-
posables, medications, and equipment in a non–facility-
based office setting.3 This study demonstrated healthcare
savings by performing awake laryngology procedures in
the facility-based setting of an endoscopy suite. ES laryn-
gology procedures represent an alternative to non–facility-
based office-awake laryngology procedures.
Performing these procedures in an ES significantly
reduces the time a patient is required to be present at
the hospital by reducing preoperative, procedure, and
recovery time when compared with the OR. A large com-
ponent of this is the time needed to safely administer,
and recover from, general anesthesia. Although anesthe-
sia time is a contributing factor for suspension microlar-
yngoscopy with laser excision of papilloma, the longer
OR times are occasionally influenced by a greater
TABLE IV.
Surgeon Efficiency.
Endoscopy
Suite (n 5 36)
Average reimbursement (US$) $506
Average time of case (min) 12.4
Ratio (US$/min) $41
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1388
TABLE V.
Predicted Total Costs to Payer Over a 3-Year Period for Laser
Excision of Papilloma and Injection Laryngoplasty.
Cost Per Predicted
P Value No. of Procedure Total Cost to
Procedures (US$) Payer (US$)
.0013
OR injection laryngoplasty 1 $2,942 $2,942
<.0001
ES injection laryngoplasty 1 $2,265 $2,265
<.0001
OR laser excision of papilloma 4.18 $3,829 $16,044
N/A ES laser excision of papilloma 7.83 $2,049 $16,005
<.0001
This theoretical model assumes a patient would have the same num-
ber of injection laryngoplasties over 3 years.
ES 5 endoscopy suite; OR 5 operating room.
disease load for OR cases as compared to ES cases. An
additional benefit to avoiding general anesthesia in the
ESis the reduced sedative effect, allowing a majority of
patients to transport themselves and return to work the
same day as their procedure.2,4 Although we did not
quantify these data, it can be inferred that it is a cost
savings to the community at large.
This study demonstrates the healthcare cost sav-
ings for ES injection laryngoplasty and laser photoabla-
tion of laryngeal papillomatosis when compared with the
respective cases performed in the OR on an individual
basis. As our billing and collection data demonstrate,
both ES laser excision of papillomas and ES injection
laryngoplasty reduce hospital and third-party payer
costs when compared to like-OR procedures (Tables II
and III). Anticipating a future healthcare environment
driven by outcomes and cost efficiency, ES awake laryn-
gology procedures represent a safe alternative with
equivalent outcomes comparable to OR procedures in the
majority of patients, resulting in overall healthcare sav-
ings.1,5 Interestingly, this study also demonstrates that
these procedures are more profitable for the hospital in
part due to the expense of running an OR and reim-
bursement contracts with third-party payers. As with
any review of a single institution’s charges and reim-
bursement, this study is biased by third-party payer
reimbursement contracts specific to the study site. It
would be strengthened by grouping multiple institutions,
hospital, and surgeon charges and reimbursements.
Although payer costs are less for a direct individual
comparison between OR and ES procedures, total payer
costs were similar for laser excision of papilloma over a
projected 3-year period. As demonstrated in the small
number of patients who only had ES laser excision of
papilloma, these awake cases occur more frequently
than the OR counterpart, where a more thorough laser
resection of papilloma can be performed. Although the
increased frequency offsets the healthcare savings asso-
ciated with an individual awake laser excision of papil-
loma, awake procedures allow patients to avoid
Operating preoperative evaluation time and costs, avoid long gen-
Room (n 5 36)
eral anesthesia times, reduce time spent in the hospital,
$362 maintain a more constant voice over time, and has over-
37.5 all less impact on quality of life, mitigating any potential
$10
increased costs.6 Furthermore, as demonstrated in this
study, ES cases may be combined with OR cases in the
Hillel et al.: Endoscopy Suite Laryngology Procedures
same patients to lessen their frequency of returning to
the OR and requiring general anesthesia.
This study demonstrated the time efficiency of ES
unsedated laryngology procedures when compared to
like procedures in the OR. As Table IV shows, the aver-
age time for ES procedures was less than one-fourth of
OR procedures. A large element of the time disparity is
the postoperative recovery time, which was almost 2
hours in OR procedures. Although these data were not
recorded by the ES (as patients do not wait in a formal
postoperative care unit), first-time and frail patients are
observed for approximately 10 to 15 minutes to make
sure they are breathing comfortably and feel well. Fur-
thermore, the large majority of patients undergoing
awake laryngology procedures with local anesthesia are
able to leave the ES and return to work or routine activ-
ity, whereas the OR patients generally return home for
further recovery from general anesthesia. Shorter ES
procedure times translate to improved reimbursement
per unit time for awake laryngology procedures
(Table V).7 The ability to perform more awake laryngol-
ogy procedures versus comparable OR procedures trans-
lates to a more efficient use of an otolaryngologist’s time.
For those practitioners who perform office-based pro-
cedures, yet find the associated net financial loss or safety
issues prohibitive, we propose an endoscopy suite, or
equivalent facility space, as a third option.3 Injection lar-
yngoplasty and awake laser treatments in the procedure
room maintains much of the efficiency of office-based pro-
cedures for both the patient and practitioner while work-
ing within regulated hospital space. This setting provides
for adequate materials and staffing reimbursement that
are cited causes of financial loss in the office.3 Although
ES suites do not function as efficiently as an otolaryngol-
ogy office, other benefits of ES procedures is the larger
physical space than many office suites, and the improved
monitoring capability and ready access to anesthesia and
their equipment in the event of an emergency. Given the
elevated blood pressure and heart rates that can be associ-
ated with these procedures, patient monitoring can pro-
vide an extra level of security during unsedated
Laryngoscope 126: June 2016
laryngology procedures that are not present in most oto-
laryngology offices.8
CONCLUSION
Unsedated ES laryngology procedures reduce
time and healthcare costs when compared with similar
individual procedures in the OR. This reveals the cost
and time savings of ES injection laryngoplasty compared
to OR injection laryngoplasty, which would be expected
to occur at a similar frequency. Given the increased
frequency for ES laser procedures relative to OR
laser excision of papilloma, total payer costs are pre-
dicted to be similar for ES and OR laser excision. ES
procedures do increase otolaryngologist and hospital effi-
ciency, an important metric in the changing healthcare
landscape. When regulated office space is not available,
endoscopy rooms represent an alternative setting for
unsedated injection laryngoplasties and laser procedures
in an effort to minimize procedure related expense, time,
and risk.
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