Medicare reimbursement for AF ablation
Uncomplicated AF ablations are billed under DRG 251 with an average reimbursement of $10,338 .
Costs of capital equipment, reusables, and disposables
Table 1 shows the cost of special capital equipment for AF ablation. The 5-year cost for the mapping systems/maintenance contracts is $375,000 for the Biosense Webster Carto™ 3 and $495,000 for the St. Jude EnSite Velocity™. Phased array ICE catheters use standard ultrasound machines; however, the rotational ultrasound catheter (Ultra ICE™, Boston Scientific, Natick, MA, USA) requires a special machine (iLab®) with a 5-year cost of $131,400. The 5-year cost ranged from $33,000–$67,000 for RF generators and $12,000–$19,000 for irrigation pumps.
The cost of ablation and mapping catheters and their respective cables and patches are listed in Table 2 along with the costs of ICE catheters and transseptal needles and sheaths. The cost of unidirectional open irrigated-tip catheters ranged from $1,500–$2,800. Bidirectional catheters were more expensive ranging from $1,700–$3,000. Catheters compatible with the St. Jude Ensite Velocity™ system ranged from $1,500–$1,900, and the special navigation catheters required by Carto™ 3 cost $2,800–$3,000. Ablation cables ranged from $170–$400. The navigation patches from Biosense Webster were $420, and those from St. Jude were $1,045. The Medtronic Arctic Front® cryoballoon cost $6,500. Its cable and umbilical cable cost $215 and $145. The Freezor® MAX focal cryoablation catheter cost $3,095. The MNS requires special navigation catheters and a disposable catheter advancement system costing $1,200. Unidirectional CS catheters cost from $1,150–$1,200 and the Boston Scientific (Blazer® DX-20) bidirectional duodecapolar catheter was slightly more expensive at $1,400.
Circular mapping catheters had more variation in cost. Fixed-diameter circular decapolar catheters ranged from $1,200–$1,540. Fixed-diameter circular duodecapolar catheters ranged from $1,400–$1,700 with all cables costing $250. Variable diameter circular decapolar and duodecapolar catheters ranged from $1,700–$1,800, and the cables cost $110–$250. The MNS requires a circular catheter advancement system costing $250. The cryoballoon utilizes a “through-the-balloon” circular mapping catheter (Achieve™) costing $1,500 which can only be used with the cryoballoon and requires a $250 cable.
The lowest cost ICE is the Boston Scientific Ultra ICE™ rotational catheter costing $1,050. The most expensive are the phased-array catheters costing $2,640–$2,800. Although the rotational ICE catheter costs $1,590 less than the phased array, it requires a separate ultrasound processor (iLab®) at a 5-year cost of $131,400; therefore, it takes 82.6 cases to begin saving on each rotational ICE catheter.
Transseptal needle costs range from $175 for standard needles to $495 for the Baylis NRG™ RF needle which requires a $150 cable. Non-steerable transseptal sheaths from range from $175–$225. The steerable St. Jude Agilis™ sheath costs $999. Cryoablation catheters require special FlexCath® steerable sheaths costing $1,200–$1,800.
The total cost for short sheaths, IV tubing, air filters, needles, syringes, defibrillation pads, and IV infusion materials is $434.90 and were not included in the following ablation scenarios as they are roughly the same for all.
Cost comparison of open irrigated-tip RF ablation catheters
Figure 1 shows the highest- and lowest-cost RF ablation catheters from St. Jude and Biosense Webster. The lowest-cost St. Jude RF ablation catheter including cables and navigation patches is the Cool Path™ unidirectional catheter costing $2,840. The lowest-cost Biosense Webster navigation RF ablation catheter with cables and navigation patches is the ThermoCool® unidirectional catheter which costs $870 more at $3,710. Because the St. Jude EnSite Velocity™ mapping system costs $84,500 more to purchase than the Carto™ 3, it requires 97.1 cases to begin saving with the Cool Path™ compared with the ThermoCool®. The most expensive St. Jude ablation catheter is the Saffire BLU™ bidirectional catheter, which costs $3,215 with cables and navigation patches and is $695 less than Biosense Webster’s ThermoCool® bidirectional catheter with associated cables and navigation patches. Due to the higher cost of the St. Jude EnSite Velocity™ mapping system, it requires 121.6 cases to begin saving the $695 with the Saffire BLU™ ablation catheter.
Estimated equipment costs for RF ablation
Figure 2 shows the lowest and highest hypothetical cost scenarios for open irrigated-tip RF ablation. The lowest-cost scenario is $6,637,and the highest is $12,603 which is 89.9 % more expensive than the lowest-cost RF equipment.
Cost of magnetic navigation equipment
The manufacturer’s list price for the Stereotaxis NIROBE® Robotic MNS is $2,875,000 with an annual maintenance contract of $104,000 per year for a total 6-year cost of $3,395,000. Assuming 200 cases/year, the robotic MNS costs $2,829 per case. It requires a disposable $1,200/case ablation catheter advancement system and $250/case circular mapping catheter drive. Figure 3 shows the lowest and highest cost projections for an RF ablation using MNS. The system requires special catheters which cost $3,590 including cables and irrigation tubing and can only utilize the Carto™ 3 mapping system. The lowest- and highest-cost scenarios for a MNS ablation are $12,261and $15,464. These costs for MNS ablation are 84.7 and 133 % higher than the lowest-cost RF equipment.
Cost of cryoballoon ablation without touch-up
Figure 4(a) shows the cost of the Medtronic Arctic Front® cryoablation balloon system assuming PVs are completely isolated by the balloon requiring no additional touch-up or mapping system. We assumed a 5-year lifespan for the CryoConsole and 200 cases/year. The lowest-cost scenario includes the use of a single cryoballoon, a steerable FlexCath® sheath with the Achieve™ circular catheter, a St. Jude Livewire™ unidirectional duodecapolar CS catheter, a rotational ultrasound, and a standard transseptal needle for a total cost of $12,847. The highest-cost cryoballoon scenario without touch-up includes the addition of the AcuNav™ phased array ICE and the Baylis NRG™ RF needle for transseptal puncture for a total cost of $15,320. These lowest and highest projected costs range from 93.6 % to 131 % above the lowest cost for RF ablation.
Cryoballoon ablation with focal cryoablation touch-up and/or RF touch-up
The costs of a cryoballoon ablation with focal cryoablation touch-up for the lowest- or highest-cost scenarios is similar to that for the balloon only ablation but requires the addition of a Freezor® MAX focal cryoablation catheter for $3,095. The lowest cost estimate requires repeated removal of the cryoballoon and insertion of the focal ablation catheter through the same sheath. The highest-cost estimate assumes the addition of a variable-diameter circular mapping catheter used independently of the cryoballoon through a steerable sheath. The total lowest and highest costs of $15,942 and $22,284 were 140 % and 236 % higher than the lowest-cost RF ablation.
Figure 4(b) shows the costs of the lowest and highest cryoballoon ablation assuming RF is needed for additional focal-segmental isolation of PVs or to make any additional lines/lesions. These costs are the same as for isolated cryoballoon ablation but require the added cost of open irrigated-tip RF catheters and cables. The lowest-cost scenario assumes that one repeatedly exchanges the cryoballoon and Achieve™ mapping catheter with the RF ablation catheter through the cryoballoon sheath. The highest-cost scenario includes the use of a mapping system, 20-pole variable-diameter circular catheter, and additional steerable sheath placed in the left atrium. The lowest and highest estimated costs of cryoballoon ablation with RF touch up range from $15,667–$22,054, amounting to 136 % to 232 % above the lowest cost for RF ablation.