Robotic surgery is an emerging procedure in Europe and Odelle Technology has had some success with coding recently. While surgical robots are widely disseminated across hospitals in European countries, the application of robots is limited to several clinical indications. Most of the studied countries have established procedure coding for robotic surgery, but reimbursement in most of the cases does not differ from reimbursement procedures performed with a laparoscopic approach. In a very small number of cases, specific reimbursement has been established for robotic surgery.

Another specific challenge is funding or willingness to pay. European countries demonstrated different approaches to endorsing robotic surgery. In some countries (like England or the Netherlands), robotic surgery is explicitly approved for funding, while in others definite conclusion has been made. In most countries, recommendations focus on robot assisted prostatectomy and nephrectomy.

Summary of the reimbursement situation in individual countries is presented below:

In England, robotic surgery is coded using a supplementary code that is used in addition to primary code for the procedure. Robotic surgical interventions in England are reimbursed only via HRG. Robot-assisted prostatectomy in prostate cancer is allocated to the specific HRG with higher reimbursement amount compared to open and laparoscopic intervention. Robot-assisted nephrectomy is reimbursed via a nonspecific HRG with higher reimbursement amount compared to open and laparoscopic intervention. Other procedures under the scope of analysis are reimbursed via a nonspecific HRGs. The HRG allocation and reimbursement amount do not differ depending on the type of the approach, except for cholecystectomy with lower tariff for the laparoscopic approach compared to open procedure. Robot assisted prostatectomy and nephrectomy are routinely commissioned by the national commissioner, NHS England. Other robot-assisted interventions are not routinely commissioned in England. In 2020, in the clinical guideline for colorectal cancer, the National Institute for Health and Care Excellence (NICE) concluded that there is no difference in effectiveness between laparoscopic and robotic surgery for rectal cancer.

In 2020, NICE initiated development of Interventional Procedure Guidance on minimally invasive radical hysterectomy for early-stage cervical cancer and published an interventional procedure consultation document. Robotic-assisted minimal invasive procedures were considered under the scope of the evaluation.
Procedure coding for robotic assistance
In OPCS-4.9 robotic surgery is coded via a supplementary code for a robotic-assisted mini approach that is used in addition to the primary code for the procedure.

• Y74.3 “Robotic minimal access approach to thoracic cavity” belongs to the subchapter
Y74 “Minimal access to thoracic cavity”
• Y75.3 “Robotic minimal access approach to abdominal cavity” belongs to the subchapter
Y75 “Minimal access to abdominal cavity”
• Y76.5 “Robotic assisted minimal access approach to other body cavity” belongs to
the sub-chapter Y76 “Minimal access to other body cavity” New procedure code introduced in OPCS-4.9 (2020) Y45.2 “Approach to organ under robotic control NEC” under sub-chapter Y45 “Approach to organ under other control”
excludes robotic-assisted minimal access approach. There are no recommendations to use this code with the procedures under the scope.

In accordance with the Manual for prescribed specialised Services (2018/2019), radical prostatectomy is commissioned by the national commissioner, NHS England. Within the National Program of Care for Cancer, there is a Clinical Reference Group named “B03. Specialised Cancer Surgery” that defines service specifications “Cancer: Specialised Kidney Bladder and Prostate [Adult].” There is a specific commissioning policy for robotic prostatectomy, developed by the NHS Commissioning Board, which defines funding criteria for this type of robotic surgery. Service “Cancer: Specialised Kidney Bladder and Prostate (Adult)” is a specialized urological cancer service. The role of this service is described in the current service specification, but the detailed specification for local urological cancer services is described in a separate document because these services are expected to be commissioned by the clinical commissioning groups (CCGs).

In France, robot-assisted procedures are not specifically coded. Coding for a laparoscopic approach can be used for robotic procedures. Also, Technical Agency for information on Hospitalizations (ATIH) created specific extension codes to monitor the interventions performed with robotic assistance in France. All the procedures under the scope of analysis are reimbursed solely via DRG. The DRG allocation and reimbursement amount is the same for open and laparoscopic approaches. One Program for Medical Economic Research (PRME) on the evaluation of total robotic assisted prostatectomy was listed as intention study in 2018 in addition to two earlier conducted economical evaluations of robotic-assisted prostatectomy and robotic assisted surgery in gynaecological malignancies in 2007-2011.

Two Clinical Research Hospital Programs (PHRC) on the robotic-assisted surgery in gynaecological oncology were also conducted with the beginning in 2010. In 2016, the French National Authority for Health (HAS) approved robot-assisted prostatectomy for reimbursement in patients with localized prostate cancer. Based on available research data, the HAS could not define the expected benefit (SA) and the level of added clinical value (ASA) of robot-assisted nephrectomy compared to open surgery or conventional laparoscopic surgery. In 2020, the HAS issued a concept note on the clinical evaluation of robot-assisted hysterectomy for benign pathology to determine its inclusion in the CCAM Nomenclature for reimbursement by the French National Health Insurance. Publication of the health technology assessment report and HAS decision was planned for October 2020; however, it has not been released yet.

In the report of the National Health Insurance Fund (CNAM) “Improve the quality of health and control spending,” issued in July 2019, the proposition to adapt the information system of the PMSI to trace the operations carried out with robotic technology was provided. This data should make it possible to carry out medical and medico-economic studies to assess the value of the robot and produce recommendations for surgeons and establishments. The following extension codes to specify robotic assistance at CCAM codes for laparoscopic procedures were implemented:
• “-30” – for interventions without robotic assistance;
• “-40” – for robotic-assisted interventions.

In Germany, robotic surgery is coded using a supplementary procedure code. In the OPS classification for 2021, the new procedure code for robot-assisted preparation of the bone and/or the joint surface (5-987.2 “Miniature robot”) was implemented. Robot-assisted procedures are reimbursed via the same DRGs as open and laparoscopic procedures, except for hysterectomy, total fundoplication, cholecystectomy and wedge resection of the liver, for which the open and robot assisted procedures are grouped into different DRGs with a higher tariff. In 2020, an application for innovation funding (NUB) for robot-assisted urological procedures by four hospitals were rejected

Robot-assisted procedures are described via a supplementary OPS code application of an operating robot” (Die Anwendung eines OP-Roboters) (5-987) in the chapter 5-98 “Special surgical procedures and operations in special care situations” (Spezielle Operationstechniken und Operationen bei speziellen Versorgungssituationen). There is a specific note that “the application of an operating robot, if not specified as a separate code, should be additionally coded (5-987 ff.)”, which relates to the entire subchapter “Operations on the urinary organs” (Operationen an den Harnorganen) (5-55…- 5- 59)”. Accordingly, the code for an operating room robot should be used as the additional code for a robot-assisted partial nephrectomy, total nephrectomy and radical nephrectomy.

In Italy, robotic surgery is not specifically coded. Nonspecific supplementary code for other computer-assisted surgery can be used to specify robot-assisted approach.

Robot-assisted procedures are reimbursed via the same DRGs as procedures with an open and laparoscopic approach. Reimbursement tariffs do not differ between open and laparoscopic approaches, except for cholecystectomy, when the laparoscopic approach leads to a different DRG with a lower reimbursement amount. Lombardy region has an additional reimbursement for the robotic radical prostatectomy kit. In 2017, the Italian Ministry of Health in collaboration with the Italian National Agency for Regional Healthcare Services has stated that the introduction and use of robotic surgery in Italy lacks an organized approach for performance, outcomes monitoring, and robust evidence generation with the evolution of the technology