AIUM: Collaboration drives musculoskeletal ultrasound

It has taken collaboration between institutions, physicians of different specialties, sonographers, and national and international organizations, according to Dr. Levon Nazarian, a professor of radiology at Thomas Jefferson University (TJU).


“The ultimate [beneficiary], which we can never forget about, is the patient,” Nazarian said. “We had to come out of our silos in order to help patients, and that is really the bottom line of why we’re in the medical field.”


He discussed the evolution of musculoskeletal ultrasound during the 2014 William J. Fry Memorial Lecture at AIUM 2014. To demonstrate how far musculoskeletal ultrasound has grown, Nazarian shared some stories from his own personal journey with the modality. After being encouraged by his mentor Dr. Barry Goldberg to attend the 1993 Musculoskeletal Ultrasound Society meeting in Florida, Nazarian elected to learn this new area of ultrasound.


Early adopters were excited about the potential and clinical benefits of the modality. Nazarian pointed to a paper he published in the American Journal of Roentgenology six years ago (June 2008, Vol. 190:6, pp. 1621-1626), which offered 10 reasons why musculoskeletal ultrasound was an important complementary or alternative technique to MRI:


  • Everyone can undergo an ultrasound
  • Ultrasound can resolve finer details than MRI
  • Ultrasound allows real-time dynamic examination
  • The ultrasound probe can be placed exactly where it hurts
  • Ultrasound can effectively image patients with surgical hardware
  • Doppler ultrasound gives important physiologic information
  • Ultrasound is better than MRI for distinguishing cystic from solid material
  • Ultrasound is better for guiding therapeutic interventions
  • Ultrasound facilitates bilateral comparison
  • Ultrasound has a more flexible field-of-view

As part of his personal learning curve, Nazarian scanned both normal and abnormal volunteers and also dispensed free ultrasound scans to patients getting MRI studies.


“When I got to a certain level when ultrasound started disagreeing with the MRI and the ultrasound was right, that’s when I stopped doing comparisons with the MRI,” he said.


Nazarian also performed clinical research and gradually began to offer musculoskeletal ultrasound as a clinical service. Between 1993 and 1997, the depth and breadth of TJU’s musculoskeletal ultrasound program grew in both the clinical and research arenas. The university also began marketing the service to referring physicians and also trained sonographers, Nazarian said.


Questioning musculoskeletal ultrasound


The modality hit a big roadblock in the 1990s, however. Paraspinal ultrasound had become a $35 to $40 million business in the U.S., typically for the evaluation of whiplash injuries. Some concerns had been raised, though, about the validity of this type of imaging study.


Thanks to the impetus of Dr. Barry Bakst, a physical medicine and rehabilitation physician in the Philadelphia area, Nazarian and colleagues performed a study that found that paraspinal ultrasound suffered from a lack of accuracy in evaluating patients with cervical or lumbar back pain (Journal of Ultrasound in Medicine, February 1998, Vol. 17:2, pp. 117-122). Nazarian later participated in an FBI investigation into a New York practice that had been performing $20 million worth of paraspinal ultrasound studies per year, which resulted in jail time for a few of the participants.


“This experience got me to realize that we really have to take care of [musculoskeletal ultrasound], and make sure that we’re making this field valid for it to go forward,” Nazarian said.


Recognizing a need for education, TJU held its inaugural musculoskeletal ultrasound course at the Jefferson Ultrasound Research and Education Institute. The course had an excellent turnout, with attendees including physical medicine and rehabilitation physicians, nonoperative sports medicine physicians, rheumatologists, orthopedic surgeons, and chiropractors.


“But there were very few radiologists, and this surprised me,” Nazarian said.


Lack of interest by radiologists


The hesitancy of radiologists to learn musculoskeletal ultrasound was a second roadblock to the modality’s growth. Radiologists were reluctant to learn musculoskeletal ultrasound due to concerns that it was too operator- and equipment-dependent, he said. In addition, the modality has a long learning curve.


“Sonographers may be insecure with anatomy and pathology, and musculoskeletal radiologists may be insecure with ultrasound,” he said.


Referring physicians are also more comfortable with MRI, and there is much higher reimbursement for MRI.


The general imaging paradigm should be to do the less expensive test first and save the most expensive test for when it’s indicated, such as what occurs with pelvic ultrasound and pelvic MRI. However, in musculoskeletal imaging, MRI is done first, with ultrasound performed only if indicated, Nazarian said.


“This is backwards, and it’s so obvious that it’s backwards,” he said. “But it takes a while to get people to buy in to the fact that we need to change what we’re doing.”


To encourage more radiologists to participate in musculoskeletal ultrasound, there was an attempt to get a CPT code for shoulder ultrasound. However, this proposal was denied by the American College of Radiology’s Economics Committee, which felt that it would take money from other CPT codes and encourage nonradiologists to use ultrasound, Nazarian said.


Who should do MSK ultrasound?


There have been a number of arguments as to why musculoskeletal ultrasound should be performed by radiologists. For example, radiologists have the most formal ultrasound training and are better suited to perform correlative imaging if necessary, Nazarian said.


There is also less chance for self-referral, which reduces overutilization and medical costs, he said.


On the flip side, there are also compelling reasons why musculoskeletal ultrasound should be performed by nonradiologist physicians. For example, it’s convenient for the patient to receive a clinical evaluation and imaging in one visit.


In addition, ultrasound by nonradiologists could reduce the need for costly MRI studies and provide guidance for interventions. This paradigm also supports portability, enabling physicians to bring ultrasound to athletic fields and other points of care.


A compromise position would be to have clinicians running ultrasound scanners in their offices. In the majority of cases, clinicians can scan and read the musculoskeletal ultrasound studies themselves. But if they can’t answer the clinical question, they would then refer the patient to the radiologist, who has more experience and higher-end equipment, Nazarian said.


“It’s not either/or; there can definitely be a middle ground,” he said.


Saving money for insurance companies


To spur more utilization, TJU researchers sought to evaluate the cost savings from the prudent substitution of musculoskeletal ultrasound for MRI. In research published in 2008 (Journal of the American College of Radiology, March 2008, Vol. 5:3, pp. 182-188), the study team estimated 15-year Medicare savings of $6.9 billion in the U.S.


“We thought it was implicit that the payors may stop paying for MRI for certain indications,” he said. “And after several years, we’re starting to see this happen.”


Another roadblock along the way was the lack of sonographer training in musculoskeletal ultrasound, Nazarian said.


This has been addressed by courses, Web-based teaching materials, anatomy books, and on-the-job training via physician and sonographer collaboration. The Registered in Musculoskeletal (RMSK) credential was established in 2012 by the American Registry for Diagnostic Medical Sonography (ARDMS), providing an added incentive for sonographers to learn.


Intraspecialty collaboration


Another important driver of musculoskeletal ultrasound has been collaboration between different specialties at the same institution, such as what took place between the sports medicine and radiology departments at TJU. This teamwork was triggered with a call to Nazarian from Dr. John McShane, then a sports medicine physician at TJU.


McShane wanted to convert arthroscopically assisted surgery to ultrasound-guided surgery, and he worked with Nazarian to develop techniques and instruments specifically for repairing injuries.


“Over 10 years, McShane devised and I provided ultrasound guidance for minimally invasive treatments for tennis elbow, plantar fasciitis, jumper’s knee, Achilles tendinosis, trigger finger, and carpal tunnel syndrome,” Nazarian said. “It was an incredible time of learning and pushing the field forward.”


Payor problems


Yet another obstacle in the path of musculoskeletal ultrasound was that payors started to deny payments for the scans in 2009. This came amidst research by TJU that documented dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists.


In 2009, Blue Cross/Blue Shield (BCBS) announced it would deny payment for all musculoskeletal ultrasound (CPT code 76880) across the board in Texas, Illinois, New Mexico, and Oklahoma.


“The policy cited musculoskeletal ultrasound as ‘experimental,’ and the irony is, they cited my own paper [on paraspinal ultrasound] to justify this conclusion!” Nazarian said.


BCBS also mentioned other reasons, such as the proliferation of diagnostic ultrasound units, and its use by individuals without proper training and under conditions of inadequate control.


Although the policy was reversed after a campaign of letter writing, phone calls, etc., it became clear there was a need for sensible policies on the use of musculoskeletal ultrasound, Nazarian said.


“Unless we curtail collective overutilization, the plug could be pulled again,” he said. “We can’t assume this is over, and we have to continue to keep our standards high to control overutilization.”


A diverse and multispecialty organization, AIUM was a natural choice to shepherd the modality, according to Nazarian. A Musculoskeletal Community of Practice was launched in 2002. In addition, AIUM has promulgated practice guidelines, training guidelines, accreditation, and courses.


“Collaboration, not competition, has allowed musculoskeletal ultrasound to flourish,” he said.

Fix My Practice – Consults In ER, April 2, 2014 | Physician Practice …

The Physicians Practice S.O.S. Group® www.ppsosgroup.com

Consults In ER

The question of how to bill for consults in the ER often comes into our “Ask A Consultant” forum.  Which typically goes something like this… our surgeon was called to the Emergency Room to see a patient in consultation. The patient was discharged from the Emergency Room. Can you tell us how to report this?

The Answer is:

First, the correct category of CPT code will be dependent on payor rules. According to the 2014 AMA CPT rules, the service is a consultation and the 99241-99245 codes are reported. Report the consultation code for all payors still recognizing this category of codes.

While, Medicare no longer reimburses the consultation service codes, you would report a CPT code from the Outpatient Codes (99201-99215) will be reported when the patient is seen in consultation in the Emergency Room and discharged to home. The emergency department of the hospital is an outpatient service thus picking from the outpatient codes instead of the inpatient codes. This would also apply if your physician did the consult on a patient in observation as this is also an outpatient department of the hospital. Your surgeon would not report the ED code 99281 – 99285 because the ED physician gets to bill these codes.

Practicing quality medicine while maintaining and managing the bottom line is a balancing act that provider’s face daily. The Physicians Practice S.O.S. Group is committed to and has helped healthcare providers across the country with new practice start ups, IRO needs, streamlining of their A/R and billing process, improving patient flow and providing practice management and compliance solutions. Feel free to call our office to discuss any needs you might have.

Fix My Practice – Consults In ER, April 2, 2014 | Physician Practice …

The Physicians Practice S.O.S. Group® www.ppsosgroup.com

Consults In ER

The question of how to bill for consults in the ER often comes into our “Ask A Consultant” forum.  Which typically goes something like this… our surgeon was called to the Emergency Room to see a patient in consultation. The patient was discharged from the Emergency Room. Can you tell us how to report this?

The Answer is:

First, the correct category of CPT code will be dependent on payor rules. According to the 2014 AMA CPT rules, the service is a consultation and the 99241-99245 codes are reported. Report the consultation code for all payors still recognizing this category of codes.

While, Medicare no longer reimburses the consultation service codes, you would report a CPT code from the Outpatient Codes (99201-99215) will be reported when the patient is seen in consultation in the Emergency Room and discharged to home. The emergency department of the hospital is an outpatient service thus picking from the outpatient codes instead of the inpatient codes. This would also apply if your physician did the consult on a patient in observation as this is also an outpatient department of the hospital. Your surgeon would not report the ED code 99281 – 99285 because the ED physician gets to bill these codes.

Practicing quality medicine while maintaining and managing the bottom line is a balancing act that provider’s face daily. The Physicians Practice S.O.S. Group is committed to and has helped healthcare providers across the country with new practice start ups, IRO needs, streamlining of their A/R and billing process, improving patient flow and providing practice management and compliance solutions. Feel free to call our office to discuss any needs you might have.

ASC Key Specialties: Ophthalmology, GI & Orthopedics Coding …


Ophthalmology, gastroenterology and orthopedics are the most common ambulatory surgery center specialties. Ophthalmology accounts for 29 percent of all ASC case volume, gastroenterology 17 percent and orthopedics 17 percent, according to VMG Health‘s ASC Intellimarker Survey 2011.

Here are a few important coding and billing issues and statistics for leaders of ophthalmology, GI or orthopedics-driven ASC leaders to know.

Ophthalmology
Several changes have been made to the 2014 Current Procedural Terminology code set. Code 0192T has been deleted and replaced with code 66183, which refers to the insertion of an anterior segment aqueous drainage device without an extraocular reservoir, according to president of Ellis Medical Consulting Stephanie Ellis, RN, CPC, in a recent Becker’s ASC Review report.

Cataract surgery with IOL insert 1 stage was the most frequently performed ASC procedure in 2012 at 16.9 percent of total volume, according to MedPAC data. Of total billed amounts from Nov. 15, 2012 to Feb. 11, 2013, 7 percent of total denied claims were for cataract surgery with IOL insert, 1 stage, according to RemitDATA.

Gastroenterology
Approximately a quarter of the 2014 CPT code changes affect GI codes, according to the American Medical Association. Additions to the 2014 CPT code set cover procedures such as esophagoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography and image-guided fluid collection drainage by catheter, according to Ms. Ellis.

Upper GI endoscopy with biopsy and colonoscopy with biopsy are two of the five most frequently performed ASC procedures at 8.1 percent and 5.8 percent of total case volume, respectively, according to MedPAC data. From Nov. 15, 2012 to Feb. 11, 2013, colonoscopy and biopsy accounted for 9 percent of all claims denials and upper GI endoscopy with biopsy accounted for 8 percent, according to RemitDATA.  

Orthopedics
There are a number of significant CPT code additions to the 2014 Medicare ASC list. “[For example], code 27415 for open osteochondral allograft, knee, open,  is  an existing CPT code, which is newly-added to the Medicare ASC list for 2014 with an average Medicare payment of $2,242,” says Ms. Ellis.

An AIS Health report released early this year indicated that orthopedic and spine procedures may be faced with increased scrutiny. One such procedure, joint replacement, has a 12.6 percent Medicare improper payment rate. Medicare contractors are now conducting pre- and post-payment review of joint replacement procedures. They expect proof of exhaustion of conservative treatment prior to surgery.

Spinal fusion has also been placed on the Program for Evaluating Payment Patterns Electronic Report list of risk areas. Coders are tasked with understanding the technologies surgeons use to ensure the codes accurately reflect procedures performed.

CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

More Articles on Coding and Billing:
Two Financial Tips to Boost Patient Volume
10 Highest Billed Urology Procedure Unexpected Denial Rates
21 Types of Healthcare Staff Who Need ICD-10 Education


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The Coltons Point Times: CPT TWIT – March Madness – Action …


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2014 Update for Insurance and Coding Specialist Programs, Test …

NCCT is an independent certification organization that has tested more than 380,000 individuals throughout the United States since 1989 for competency in these roles: Medical Assistant, Phlebotomy Technician, Insurance and Coding Specialist, Medical Office Assistant, Patient Care Technician, ECG Technician, Tech in Surgery – Certified (NCCT), and Certified Postsecondary Instructor®.

HITC (Health Information Technology Coding) – St. Vincent's College

Bridgeport, CT, March 11, 2014 – St. Vincent’s College will be offering the Health Information Technology Coding certification program beginning in fall 2014. This new 30- credit certificate program will provide students with skills necessary to enter or advance in billing and coding for physician practices and hospital coding services.

“We are very pleased to be offering the HITC Certificate Program at this critical time when the implementation of the (ICD-10) International Classification of Diseases-10th Edition is taking place.  With the addition of this program St. Vincent’s College will be a provider for critical education and training in coding needed by the health care community in the greater Bridgeport area.” said Martha Shouldis, President /CEO of St. Vincent’s College.

According to the U.S Department of Labor’s Bureau of Labor Statistics the employment of medical records and health information technicians is expected to increase 21 percent by 2020.

Graduates of this program will learn about anatomy & physiology, pathophysiology, pharmacology, computer systems, medical terminology, reimbursement methodology, clinical data analysis, legal and compliance aspects of healthcare, healthcare data structure and delivery system, and intermediate/advanced ICD diagnostic/procedural and CPT coding.  They will also have the opportunity for internships or on-line practical experience that will allow them to experience their profession in a real working environment.

For more information about the HITC Program at St. Vincent’s College please contact the Continuing Education Department at 203-576-5651 or continuinged@stvincentscollege.edu.

For more information about the courses for this program please visit the Continuing Education web page:

http://www.stvincentscollege.edu/programs-offered/continuing-ed-certificates/health-information-technology-coding-hitc/