Diagnostic Ultrasound for Rheumatology?

[drk310]

I'm a rheum fellow nearing graduation. Currently being trained (not certified) in diagnostic ultrasound.

Has anyone out there found it useful to implement in their practice? Has anyone used this in place of getting xrays on some of your patients?

It seems to be the one procedure that rheumatologists can do that has reasonable reimbursement (unlike ultrasound guided joint injections.) Just wanted to get a sense of its clinical utility in day to day practice.

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[drfunktacular]

I trained in it (probably 150 scans/procedures, didn't certify). I have had two jobs since graduating fellowship and in neither job have I pulled out the US more than once every 3 or 4 months, and even then usually just to do a quick un-billed scan to determine synovitis vs effusion or something. It may or may not be worthwhile on a reimbursement basis, but I have not really had the desire to try to work it into my day to day practice.

You could probably do it in an efficient manner but it would require a lot of preparation and training of your staff to make it easy on you. If it takes 20 minutes for you/your staff to get the machine pulled out, booted up, cleaned off, demographics entered, proper probe connected, settings dialed in, room configured, patient positioned, etc before you even START the scan, much less document the findings, you're just not going to do it.

My opinion, which seems to be shared by most people in private practice that I've talked to, is that you could see another patient or two in the time it takes you to set up and do a scan, and produce more than you do from the scan.

It might be more practical if, for example, you're working in a big-ish multispecialty clinic with PCPs and others nearby who send you patients for same-day diagnostic scans or procedures ("swollen ankle", "shoulder hurts", "bump on wrist", "needs SynVisc injection", etc), particularly if: 1) you have the US set up and ready to go when they come in throughout the day and office staff who know how to get the patient positioned and the equipment prepared before you walk in, 2) you can do it on specific days and make your own schedule lighter to accommodate the scans, and 3) you're not necessarily paid solely on a production basis.

 

[drk310]

I figured it's usually the set up that takes the most amount of time. I like the idea of having a half day dedicated solely to ultrasound, the issue in my mind is to get patients to take time off from their schedule to come back in just for the ultrasound, but I know of people who do this.

The boot up time on all the machines I've used are ridiculous! Granted some of these machines are older. Hoping the newer ultrasound machines have a fast boot up time -- or else I'll just have to have a room dedicated to US and leave it plugged in and powered up.

I'm starting my own practice so it's not really a production issue through a large entity. I have found that as I've gotten more used to ultrasound it really does add value to ruling out things.

Thanks for your input!

 

[drfunktacular]

If you're starting your own practice, some of the problems are actually magnified.

Some of the machines are quite expensive, even used (think like Honda Civic prices). The ROI is not great in most practices unless you are using it a LOT (ie, maybe more than is really indicated).

Setting aside an entire exam room compounds the cost because that's square footage you're paying rent on that may not be paying for itself if you aren't using the US machine frequently (and recall that you're already having to pay the overhead on the machine itself, in addition to rent).

Reimbursement for the scans is also more or less set by fiat by CMMS, so it could be cut in half next week and everybody who owns an expensive machine and has an ultrasound room in their clinic is suddenly upside down on US.

Which is not to say that you shouldn't use US or incorporate it into your practice if you love doing it and you think it significantly improves your patient care. But these are definitely issues you need to think through before you burden your new practice with an extra $20k in debt that doesn't pay itself off rapidly.

 

[NewYorkDoctors]

Use of a portable tablet ultrasound (I use a Philips Lumify... and no I do not get royalties) may help hasten some of the time constraints.
In the hospital, the tablet hooks onto a tablet container which straps to my belt and then the probes are snug in my cargo pant scrub pockets.

In the office setting, the tablet and probes are hooked up at all times next to the PanOptic funduscope, the otorhinoscope, the hammer, the varying frequency tuning forks, the monofilament, the bioimpedance body fat percentage device, the electronic stethoscope, etc.... This doesn't require extra staff.

Honestly its quite fast and no more time consuming than doing a "full" physical examination, especially if the patient is already in a gown.

However, I admit I only use the ultrasound for point of care purposes as an adjunct to physical exam so I don't bother with proper documentation and billing (which is what would eat into your time). Though I will save my images into the chart and I always tell the patient that he/she may still need a formal radiology/cardiology study for precise quantification and that I my skill is only as a brief screening and not a full study etc...

I will admit if I had to load all the proper images and then make proper documentation, then this would eat into a lot of my office productivity in seeing patients.

Of note I am not a rheumatologist.

 

[bronx43]

Use of a portable tablet ultrasound (I use a Philips Lumify... and no I do not get royalties) may help hasten some of the time constraints.
In the hospital, the tablet hooks onto a tablet container which straps to my belt and then the probes are snug in my cargo pant scrub pockets.

In the office setting, the tablet and probes are hooked up at all times next to the PanOptic funduscope, the otorhinoscope, the hammer, the varying frequency tuning forks, the monofilament, the bioimpedance body fat percentage device, the electronic stethoscope, etc.... This doesn't require extra staff.

Honestly its quite fast and no more time consuming than doing a "full" physical examination, especially if the patient is already in a gown.

However, I admit I only use the ultrasound for point of care purposes as an adjunct to physical exam so I don't bother with proper documentation and billing (which is what would eat into your time). Though I will save my images into the chart and I always tell the patient that he/she may still need a formal radiology/cardiology study for precise quantification and that I my skill is only as a brief screening and not a full study etc...

I will admit if I had to load all the proper images and then make proper documentation, then this would eat into a lot of my office productivity in seeing patients.

Of note I am not a rheumatologist.

Did you buy the Lumify outright or rent it?
Also I'm waiting on the ButterflyIQ to come out, which is under $2k for the probe. They were able to develop a system that bypasses the expense piezoelectric crystals.

POC MSKUS reimbursement got a HUGE bump up this year, so if you're not using it on a regular basis, you're missing out on a lot of income.

 

[NewYorkDoctors]

Did you buy the Lumify outright or rent it?
Also I'm waiting on the ButterflyIQ to come out, which is under $2k for the probe. They were able to develop a system that bypasses the expense piezoelectric crystals.

POC MSKUS reimbursement got a HUGE bump up this year, so if you're not using it on a regular basis, you're missing out on a lot of income.

Outright purchase. A long term investment. Upon completion of all of my fellowships and obtaining certification for certain procedures (namely Kidney/Bladder from an outside certification course in Emory, and then POCUS and Lung US after possibly taking the ASE ACCE examination.. then maybe take the ASE Echo Boards... as a PCCM person), I might start to employ them as an official thing. But for right now before final certification, I am merely using this as an extension of physical exam.

But honestly, I would probably not make these things a routine part of practice because the time it takes to obtain images and document reports (and because that would be nearly as bad as ordering unecessary carotid duplexes for "dizziness"). But if ever confronted with a diagnostic dilemma that was resolved or at least helped by an examination (probably mostly ruling out something egregious), then I would want to be able to document and bill accordingly.

 

[drfunktacular]

POC MSKUS reimbursement got a HUGE bump up this year, so if you're not using it on a regular basis, you're missing out on a lot of income.

This may be true but is definitely a YMMV situation. Also as I noted above reimbursement could just as easily be halved next year. I would consider carefully with a practice manager if someone is thinking of buying a machine.

For me personally I would just rather see an extra couple of patients in the time I would otherwise spend recording/documenting US ¯\_(ツ)_/¯

 

[bronx43]

This may be true but is definitely a YMMV situation. Also as I noted above reimbursement could just as easily be halved next year. I would consider carefully with a practice manager if someone is thinking of buying a machine.

For me personally I would just rather see an extra couple of patients in the time I would otherwise spend recording/documenting US ¯\_(ツ)_/¯

Your staff should be the ones to upload images to notes, and you should be using dotphrases for majority of the documentation. There is a way to utilize US and bill for it without having it significantly slow down your clinic.

However, if you're in an employed position with low potential for productivity bonuses (and low autonomy for training staff), then it's probably not worth the trouble.

 

[drfunktacular]

True, unless you just really love doing scans and couldn't imagine practicing effectively without it. But I personally never really felt that way. I guess here (as with so many other things) don't do something just for the $$, do it because you think it helps your patients and/or you like doing it

 

[bronx43]

True, unless you just really love doing scans and couldn't imagine practicing effectively without it. But I personally never really felt that way. I guess here (as with so many other things) don't do something just for the $$, do it because you think it helps your patients and/or you like doing it

I think we discussed this before, but I still maintain that ultrasound should be used for almost every patient with joint pain who already has a diagnosis of inflammatory arthritis. It should also be used for a good portion of patients with joint pain but does not have inflammatory arthritis. Making money would be an added benefit. My point was that you can have a system where it would be efficient to accomplish both tasks.

 

[drk310]

@bronx43 I actually had the butterfly IQ people come out and do a quick demo for me and one of my attendings who is an US expert...it's a cool, reasonably priced device. The problem is they don't have power doppler, just color doppler. The grayscale is really good but the color doppler to eval for synovitis may not be the best even though the device is FDA approved for MSK imaging. I don't know if you can use it reliably for diagnostic ultrasound just yet. I've had my eye on it for several months as well though.

 

[ranitidine313]

I think we discussed this before, but I still maintain that ultrasound should be used for almost every patient with joint pain who already has a diagnosis of inflammatory arthritis. It should also be used for a good portion of patients with joint pain but does not have inflammatory arthritis. Making money would be an added benefit. My point was that you can have a system where it would be efficient to accomplish both tasks.

Can I PM you?

 

[Rheumination1]

Using the Phillips lumify as well. I think US is great. It’s damn quick once you get used to it. 2 min complete shoulder, knee or mcp gets reimbursed nicely. Also has helped me with a couple patients with negative inflammatory markers and active synovitis on Doppler. Treated as inflammatory arthritis helped treat their symptoms.

ACR has a RhMSUS course and there’s also USSONAR. Highly recommend to do it.


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[bronx43]

Using the Phillips lumify as well. I think US is great. It’s damn quick once you get used to it. 2 min complete shoulder, knee or mcp gets reimbursed nicely. Also has helped me with a couple patients with negative inflammatory markers and active synovitis on Doppler. Treated as inflammatory arthritis helped treat their symptoms.

ACR has a RhMSUS course and there’s also USSONAR. Highly recommend to do it.


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What's the benefit of having the certification? I feel like it's just a scam for these organizations to make money. If you're actually trained on how to do MSKUS, then paying ACR $1500 doesn't make you any more proficient.

 

[Raryn]

What's the benefit of having the certification? I feel like it's just a scam for these organizations to make money. If you're actually trained on how to do MSKUS, then paying ACR $1500 doesn't make you any more proficient.

Not sure about Rheum, but for Endo, there's some insurance companies that are starting to require the certification (in our case, Endocrine Certification in Neck Ultrasound = ECNU) to reimburse. Only in New Jersey so far, but the worry is others will start jumping on the bandwagon, so we have some leaders in our field basically telling us we should go get certified pre-emptively before it's required (I'm not bothering as I don't plan on doing ultrasounds in practice at the moment, but that's what they say).

 

[drk310]

I don't believe in preemptively getting certification unless it's a known requirement for reimbursement. Can anyone comment on whether USSONAR really makes a difference? @bronx43 have you done the course?

West coast doesn't require certification for reimbursement atm but I think it's a different story in the northeast and elsewhere, not too sure about the details though.

2 votes for Lumify? Will need to check this US out. Thanks for the feedback.

 

[bronx43]

Not sure about Rheum, but for Endo, there's some insurance companies that are starting to require the certification (in our case, Endocrine Certification in Neck Ultrasound = ECNU) to reimburse. Only in New Jersey so far, but the worry is others will start jumping on the bandwagon, so we have some leaders in our field basically telling us we should go get certified pre-emptively before it's required (I'm not bothering as I don't plan on doing ultrasounds in practice at the moment, but that's what they say).

They can do that, but the problem is that so few people have the certification, that if they put that stipulation, they will essentially destroy ultrasound overnight. I mean...it's possible, but at this point in time, I don't think there's a movement towards requirement of certification.

 

[Rheumination1]

They don’t require certification for reimbursements now. But the RhMSUS is only 5 years old. It’s going to start becoming a requirement.


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[Rheumination1]

I don't believe in preemptively getting certification unless it's a known requirement for reimbursement. Can anyone comment on whether USSONAR really makes a difference? @bronx43 have you done the course?

West coast doesn't require certification for reimbursement atm but I think it's a different story in the northeast and elsewhere, not too sure about the details though.

2 votes for Lumify? Will need to check this US out. Thanks for the feedback.

I can vouch for USSONAR it was a great experience and really forces you to learn the ins and outs of MSKUS. Of course I did it as a fellow so it was covered with scholarship and CME. Didn’t spend a dime on it.


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[bronx43]

They don’t require certification for reimbursements now. But the RhMSUS is only 5 years old. It’s going to start becoming a requirement.


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How do you know this?

 

[Rheumination1]

I believe Florida already requires either certification (radiology or RhMSUS) for diagnostic MSKUS. NJ/PA was supposedly thinking of following FLorida. RhMSUS became a thing so the MSKUS didn’t get taken away from rheumatologists.


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[drk310]

@Rheumination1 do you find the color doppler on the philips lumify to be enough to pick up active synovitis? Have you ever compared it to power doppler or perhaps getting and MRI hand to eval for synovitis in questionable cases where the color doppler on US didn't pick it up? I've only practiced with power doppler which is supposed to be more sensitive than color. I'm curious to hear more about the lumify. Thanks.