An interview with Katharine L. Krol, MD

The new president of the SIR discusses the draw of interventional radiology, coding challenges, and the diverse future of her specialty.

By Katharine L. Krol, MD

What ignited your interest in radiology?
I had no initial interest in radiology. I went to medical school wanting to take care of patients, probably in a family practice. My first real interaction with a radiologist was not favorable. However, I did a rotation in radiology and figured out that I could see things on films that my fellow classmates could not see. About that same time, I was dating a fellow med student who said he couldn’t date me unless I was going into radiology (thinking that I would eat bon bons and work 10 to 2). Fortunately, I fell in love with radiology, the technology, the ability to make diagnoses, and working with the entire spectrum of specialists and diseases. Unfortunately for my husband, I took a “wrong turn,” and absolutely fell in love with IR. It combined the ability to get to know patients and to help manage them with the technology of radiology.

At the time I went into radiology, PTAs were just being done for the first time. What cooler thing could be done? I was good with my hands and got some terrific encouragement from Dr. Gonz Chua, a staff interventionist who was my main mentor and teacher.

How would you describe your practice?
I work in a large cardiovascular surgical practice. We have two IRs, 13 peripheral vascular surgeons (one of whom does 80% IR, two of whom do some IR), and 20 cardiovascular surgeons. We practice in large hospitals in Indianapolis and see a large number of patients with a wide variety of vascular problems. My group started Vein Solutions, which has several franchises nationwide, giving us many referrals for venous problems in addition to our large arterial practice. This arrangement has been advantageous for all of us. The presence of good IR in the peripheral vascular practice has allowed us to expand our services for patients and to offer them the entire spectrum of treatment options, tailoring the care for each patient. It has kept us competitive in a competitive market.

Can you describe your previous involvement with the SIR, and your current role?
I have been involved at several levels, but predominantly in the Health Policy and Economics division of the society. I began with committee work for coding and reimbursement and edited the society’s coding guide for a couple of years. I got involved with Government Affairs, and was co-chair and then chair of the Economics committee. I served on the executive council as Health Policy and Economics councilor and then served as secretary of the society, president-elect, and will become president during the meeting in Toronto. I have been active in education, including courses on coding and reimbursement, as well as several areas of clinical practice (predominantly vascular). I currently serve as CPT Advisor for the SIR.

Discuss your role as co-PI of the CREST trial.
I have an active carotid stent practice and have been involved in several carotid artery stenting (CAS) clinical trials. I am PI of the CREST trial at my institution, but we have yet to enroll a patient in the trial. My personal practice referral pattern is exclusively patients who are at high risk for surgery. My surgical partners see the patients who are not at high risk for surgery and, while they offer participation in the trial to patients, our patients are unwilling to be randomized. I strongly support this trial and the ongoing ACT trial. We need these results to be able to move to the next level in CAS for patients who are not at high risk for surgery.

Why does coding interest you? How did you initially become interested in coding?
I was new in practice when several coding changes occurred, so it fell to the youngest member of the group to learn the changes. Fortunately, it was interesting to me. I became further involved as a committee member for the SIR. I think that it is a form of patient advocacy to help make procedures available to patients that will improve their overall health and well-being. Procedures will not be available if they are not reimbursed. There are so many pressures on the health care system and never enough money to cover everything. The people in charge of deciding coverage and payment need input from expert physicians to help them spend our health care resources as wisely as possible.

We think it is safe to assume that many people find the issue of coding to be a complicated matter. Do you anticipate the future of coding to be moving toward simplification of the process, or the opposite?
It looks to me like it will get more complicated, at least in the short run. Although we have tried to simplify coding in the past few years by applying for “bundled” codes in the appropriate situations, single codes do not work for many interventional procedures. Many of our procedures are done in so many variations and permutations that single codes for each of those would make the number of codes required overwhelming and ridiculous.

Unfortunately, the more complex the coding system is, the more difficult it is to code correctly and uniformly across all practices. There are numerous sources for “expert” education on coding for the same procedure, and these sources are often disparate. Sometimes there is not a clear, correct answer for a coding issue. I personally am finding it difficult to keep up with numerous edits that are put in place to supposedly provide clarity or to decrease coding errors or abuses.

In your opinion, what is the best way to educate physicians of changes in the codes?
We have a number of ways for educating IRs on new coding information. These include blanket e-mails to SIR members, publishing a new edition of the SIR coding guide annually (supplemented with the abdominal aortic aneurysm and thoracic aortic aneurysm endovascular coding guide that is separately published with the SVS), coding workshops at our annual meeting, and a service to answer members’ coding questions. Some years we have also had cybersessions in January to educate members about changes for the new year and to address areas that seem to be hot topics. We publish coding education in our IR News publication and focus on areas that seem to be causing problems or where we are recommending changes. We work with the AMA, SVS, ACC, ACR, and RBMA to clarify areas of concern in coding.

What changes would you recommend in coding education?
The AMA has just made a change to how articles are written for The CPT Assistant, trying to give it more authority. Coding education is not always uniform. There are many “experts” who educate on coding, and they often do not agree. Having an ultimate authority would be helpful, and I believe that is what the AMA is trying to do with its changes for The CPT Assistant. I find it interesting to get into discussions with other “experts” sometimes. Having developed new codes and taken them through the CPT and RUC process, I often have a very clear understanding of the construction of the code and its proper use. Other experts frequently disagree and have other opinions of how the codes are constructed.

What do you anticipate is the future direction of interventional radiology?
IRs will continue to expand their clinical practices and will be competitive in providing care in multiple arenas. IRs may need to subspecialize, especially in high-volume practices. Interventional oncology will bring exciting new therapies to cancer patients, and those procedures could consume the time for some IRs. Vascular procedures will continue to be a vibrant part of the IR practice. I believe that outpatient IR labs will continue to develop despite economic challenges and practice challenges. Many hospitals are unable to expand the IR department to accommodate increasing volumes, and patients are waiting longer for procedures to be done. The outpatient facility can more conveniently provide care for many patients who are having procedures done that are safely performed in an outpatient lab.

Additionally, I believe that there will be many ways IRs can practice. They may continue to work within a diagnostic radiology group, either doing part-time IR or full-time IR. They may choose to align with other clinical specialties, depending upon their area(s) of interest and expertise. We are making changes in the way we train IRs, and I believe that we will recruit physicians into IR from a variety of pathways, not just from diagnostic radiology, which should open the field to those who previously were unaware of the specialty and all it has to offer. That should also draw people with clinical skills who like to practice clinical medicine and manage patients to become involved in the field.

IR is the future of medicine being practiced today. The minimally invasive therapies that we currently offer will be proven to be beneficial and will continue to expand. The history of IR is one of amazing innovation, and it will continue to be so in the future.

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Endovascular Today is a publication dedicated to bringing you comprehensive coverage of all the latest technology, techniques, and developments in the endovascular field. Our Editorial Advisory Board is composed of the top endovascular specialists, including interventional cardiologists, interventional radiologists, vascular surgeons, neurologists, and vascular medicine practitioners, and our publication is read by an audience of more than 22,000 members of the endovascular community.