thoughts on EM ultrasound?

[eddieberetta]

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Just wanted to know what you guys think about EM ultrasound, what its scope should be, and when (if ever) you should defer (or should I say refer) to radiologists.

I'm a rads resident but don't mince words...

 

[mikecwru]

Originally posted by eddieberetta
Just wanted to know what you guys think about EM ultrasound, what its scope should be, and when (if ever) you should defer (or should I say refer) to radiologists.

I'm a rads resident but don't mince words...

Typically, ED U/S are performed in the setting of emergent conditions looking for findings that may rule-in a disease. If the finds aren't present, then usually a radiology formal u/s gets done which comments on the entire anatomic area and can be used in the process of ruling-out a disease. AFAIK, both studies can be billed for.

 

[margaritaboy]

Certain residencies I interviewed at offered certifications or training in U/S, which have apparently made for some interesting career opportunities for some residents after their residency.

Does anyone have know where to find out more information about this? What are the certifications, what do they mean for EM, what can you do with them, etc.??

I'm trying to figure out whether this is something I should look for in a program.

 

[ERMudPhud]

Originally posted by margaritaboy
Certain residencies I interviewed at offered certifications or training in U/S,

It will make you more competitive when applying for ED jobs especially academic ones. It may allow you to be credentialled for ED U/S at your new job without documenting every study you ever did or getting your first 6 months worth of studies at your new job overread by radiology. It wont allow you to replace the radiologist

I use US for focused questions. Is there free fluid in the abdoment? Is there an IUP? Is there cardiac activity? How big is the aorta? Is there an abcess under all that induration? It is also invaluable for procedures-lines, thoracentesis, paracentesis, etc... I wouldn't practice without it.

 

[Primate]

We have one faculty who uses US for everything from trauma (understandable) to asthma (still trying to figure that one out). I suppose when you're a hammer, all the world looks like a nail.

 

[roja]

We have an ultrasound fellowship in my residency. (I intend to do a fellowship as well). We start doing u/s as interns. We document them all. We also have a 2 week u/s rotation where all you do is scan in the Ed.

Some of the residents graduating are level 2 certified. This has apparantly made a big difference when they are intereviewing in the private sector. U/S in the ED by certified EP's can make a department lots of money.

It is also infinately useful: Gallstones, IUP, ectopic, AAA (I diagnosed one of these on a little old lady with very vague abdominal pain.), hydronephrosis, FAST, cardiac. and as mentioned line placements.

I was never interested in U/S as medical student and didn't think about it when I was interviewing. Now, I love it.

 

[EMRaiden]

I trained a program with a very strong U/S program. We had an U/S elective and received monthly lectures. That being said very few hospitals have U/S avaliable in the ER for you to use, so don't judge a program on whether or not they have U/S. (If they don't and you really want more training take a course (www.emergencyultrasound.com) or do a rotation at a place that offers it. There are other skills that are much more important that being able to do an U/S--- read an EKG/CXR/Head CT/etc.

That being said, I find U/S to be an invaluable tool in the exam of my patients- especially pregnant VB's. While my partners shun them, knowing it will be a multi-hour process, I can do a pelvic, do an U/S (as an extension of the pelvic), if I see an IUP-- home, no IUP-- call OB.

I would argue that knowing how to U/S may be a plus when interviewing, but not knowing will not hurt you.

 

[The White Coat Investor]

U/S in the ED is fraught with problems. The smart EP will use it only for focused applications, on technically easy exams, and will defer for a formalized ultrasound fairly frequently. For example, it doesn't take much training to learn to see if there is tamponade, or free fluid in the abdomen, or gallstones/radiologic murphy's sign in the gallbladder, or a particularly large AAA. Seeing an IUP on transvaginal U/S is a bit harder, and doing pelvic U/S looking for TOAs and ovarian masses is downright difficult. Clearly, ED US is a way to speed up diagnosing, which is important in some things (tamponade, free fluid, AAA, Ectopic) and merely convenient in others (gallstones.) I don't think the questions of "What can EPs do reliably with ultrasound and when should they order a formal U/S?" will be answered for a decade yet.

 

[droliver]

Have you heard of ER physicians actually submitting billing on these? There was some consideration in the past by the surgeons about submitting billing for FAST scans for trauma but for liability issues it (the interest) got tabled & everyone's recommendations were NOT to submit billing for it (there wasn't even an ICD-9 code for it @ the time ~2001-2002)

 

[drpcb]

I have done nearly 300 scans (overread and QA'd) during my first 1.5 years of residency and find U/s absolutely incredible. By the end of residency, I will be RDMS certified, and will have 500 scans completed to meet the even stricter ACR requirements to become an "interpreting physician." http://www.acr.org/departments/stand_accred/accreditation/dmap/ultrasound/ultrasoundReq.pdf

This is all through on-the-job training, and not with additional elective time. I use it for the following:

1)r/o DVT (or baker's cyst)
2)biliary tract disease
3)hydronephrosis
4)FAST
5)AAA
6)pericardial effusion
7)central line placement
8)paracentesis
9)confirm IUP
10)retinal detachment

Some of my colleagues in addition use it for joint aspirations and FB localization.

I agree with the growing consensus that elective or semielective central line (IJ) placement should be ultrasound guided only. It is so easy that once you do it you will never go back.

I realize some ED's do just fine without emergency ultrasound, however I find it incredibly useful.

As mentioned previously, it is best for ruling in disease, however, one eventually gains an expertise allowing effective rule out in many cases.

 

[eddieberetta]

Originally posted by droliver
Have you heard of ER physicians actually submitting billing on these? There was some consideration in the past by the surgeons about submitting billing for FAST scans for trauma but for liability issues it (the interest) got tabled & everyone's recommendations were NOT to submit billing for it (there wasn't even an ICD-9 code for it @ the time ~2001-2002)

Yes, to my understanding, there is some kind of limited US modifier that is typically used for billing. Try a google search -- there are on-line refereces.

 

[drpcb]

Medicare (or anyone else for that matter) does not discriminate between a radiologist, obstetrician, emergency physician, maternal fetal medicine specialist, family practitioner, etc. All of these are considered "interpreting physicians"

"Medicare does not prohibit emergency medicine physicians from billing ultrasound CPT? codes. The service must be medicallynecessary and within the scope of the physician?s license. In someMedicare carrier jurisdictions, the physician who performs and/orinterprets the study must be capable of demonstrating relevanttraining and experience"

"The recommended code for Focused Abdominal Sonography for Traumais the limited abdominal ultrasound code--76705. This code isrecommended since it is unlikely the physician will be doing a completevisualization of all the anatomical structures within the abdomen inthis kind of examination."
http://www.sonosite.com/products_literature_files/billing_emed_ultrasound_903.pdf

 

[drpcb]

By the way: Kudos to the radiologist in training who started this thread with an open minded air. This should not be taken for granted.

In many institutions there is much drama with respect to EP's performing ultrasounds. This is for the most part because other non-radiologists performing US (MFM, OB, FP) etc. have traditionally done it outside of the hospital. With EPs and US, the radiologists are (understandably) concerned that someone is coming into their house and taking their work from them. I can sympathize, although ultimately I do feel that it serves the best interest of the patient when a physician can perform and intrepret bedside ultrasound immediately 24 hours a day, and in many institutions this is difficult for radiologists to offer.

EP's will never be able to offer comprehensive, complete ultrasounds of the whole body, unless they want to start a new career. This ability should and will remain within the domain of the radiologist, to whom it should be DEFERRED and REFERRED.
😉

 

[droliver]

drpcb,

thanks for the insight!

A question: If people submit billing on this, what happens when say an ER physician does a FAST scan, vaginal U/S, RUQ U/S, etc... & then they call the Surgeon/OB/PCP,etc... Who either 1) repeats the study themselves (ie. trauma surgeon or OBGYN) or 2) asks for the study to be interpreted by radiology. I assume the 3rd party payer responsible for this is not going to pay twice for interpretation of the study. Who get's paid?

 

[margaritaboy]

Above, posters talk about being level 2 certified, or RDMS certified. Questions:

What exactly is that?

What training does it entail to become RDMS certified, level 2 certifed or level 1 for that matter.

What are the differences between them and what exactly are you certifed to do?

Anyone have an explanation or a link I can follow for that info?

Thanks!

 

[margaritaboy]

OK, so I found this site: http://www.ardms.org/ but I am still not clear on the above questions.

Someone please lend a hand...

 

[peksi]

There are two concepts here that require clarification.

First: "Hospital Credentialing" is just that, approval or a pathway within a specific hospital or hospital system (eg Kaiser) that states that a physician, RN, PA whomever is approved to perform certain duties or proceedures. For EM US the credentialling varies from hosital to hospital. hospitals all have multispecialty committees that govern over these proposed credentials. Some have credentialling that is like a switch off/on you are either fully credentialled to perform specific or a series of EM US or you are not. this relates to a training or previsioanl stage and a credentialed stage.

Some programs have a step wise or level credentialing most notably; level 1,2,and 3. A sample is outlined in the ACEP US Guidlines document.

Other Societies, AIUM, ASE (echocardiography) designate s a similar nomenclature but the threshold numbers to attain these levels are much different, much higher and do not really jive with EM US focused aspects.

Certification is a diferent issue. Generally certification is provided by a nationally recognized organization. Certifications may be included as part of a requirement for some credentialing (eg ACLS, PALS). Eg I suspect that at your institution ALL Electrophysiolgy cardiologists must me "trained and certified by ACC" in EP cardiology today to get EP interventional priveledges in the cath lab.

The ARDMS is an organization primarily for Ultrasound Sonographers (General, Vascualr, Echo and Breast) that functions much like ABEM or AOBEM the set criteria that individuals must meet in order to have the oppertunity to 'sit" for their Certification. They have defined tracts that are reasonable for physicians, radiology, cardiology, general and EM physicians. Understand that ACEP does not support the view that such certification is needed or warrented. As of yet NO EM organization ACEP, AAEM, or SAEM has moved toward national certification for EM US and they probably will not in the future. The issue is clear however. ARDMS is a nationally recognized credential within many hospitals this is a bonus from this point. From may point i reccomend one evaluate it, see if they meet the criterial and make their own decision.

Hope this helps,
Paul

 

[roja]

Originally posted by peksi
There are two concepts here that require clarification.

First: "Hospital Credentialing" is just that, approval or a pathway within a specific hospital or hospital system (eg Kaiser) that states that a physician, RN, PA whomever is approved to perform certain duties or proceedures. For EM US the credentialling varies from hosital to hospital. hospitals all have multispecialty committees that govern over these proposed credentials. Some have credentialling that is like a switch off/on you are either fully credentialled to perform specific or a series of EM US or you are not. this relates to a training or previsioanl stage and a credentialed stage.

Some programs have a step wise or level credentialing most notably; level 1,2,and 3. A sample is outlined in the ACEP US Guidlines document.

Other Societies, AIUM, ASE (echocardiography) designate s a similar nomenclature but the threshold numbers to attain these levels are much different, much higher and do not really jive with EM US focused aspects.

Certification is a diferent issue. Generally certification is provided by a nationally recognized organization. Certifications may be included as part of a requirement for some credentialing (eg ACLS, PALS). Eg I suspect that at your institution ALL Electrophysiolgy cardiologists must me "trained and certified by ACC" in EP cardiology today to get EP interventional priveledges in the cath lab.

The ARDMS is an organization primarily for Ultrasound Sonographers (General, Vascualr, Echo and Breast) that functions much like ABEM or AOBEM the set criteria that individuals must meet in order to have the oppertunity to 'sit" for their Certification. They have defined tracts that are reasonable for physicians, radiology, cardiology, general and EM physicians. Understand that ACEP does not support the view that such certification is needed or warrented. As of yet NO EM organization ACEP, AAEM, or SAEM has moved toward national certification for EM US and they probably will not in the future. The issue is clear however. ARDMS is a nationally recognized credential within many hospitals this is a bonus from this point. From may point i reccomend one evaluate it, see if they meet the criterial and make their own decision.

Hope this helps,
Paul

Paul-

excellent point. Our ED U/S director always covers this point first when he talks about credentialling.. That the most important one is the one within your own hospital. If your hospital doesn't credential you it doesn't really matter all that much.

Do you guys make your attendings certify by region or do the entire ACEP II at once? Here they can become certified in one area and then another (vag, biliary, etc)

 

[margaritaboy]

Thanks for the info Paul. Let me ask this to drpcb, Paul, or anyone else that is knowledgeable:

Does obtaining a certain level of certification, RDMS for example, allow EP's any special privlages in the use, interpretation, or billing of sonography?

Or, is the use of sonography by EPs and its interpretation, billing etc. strictly a function of hospital credentialing?

 

[margaritaboy]

oops. I didn't see roja's reply. I take that to mean that it is really a function of hospital credentialing then.

Let's suppose that one is both certified and credentialed at a hospital. Can I assume that you may then use, interpret, and bill for sonography, which an uncertifed or uncredentialed EP could not?

 

[drpcb]

Medicare specifically states that any "qualified physician" can bill. Some PPO's may require supporting documentation (RDMS, ACR, etc.) that they are "qualified." They also state that they will not pay again for repeat scans by radiology used solely for QA purposes. That is, a repeat scan by rads to follow progression of a pericardial effusion is billable if it is to confirm no worsening in a clinical picture that supports a repeat scan. A scan to confirm the ED finding of pericardial effusion would not be billable, or rather payable, if the ED had already billed for it.

One major point here, is that being a "qualified physician" does not necessarily mean your facility will start billing your ED ultrasounds, primarily because of "turf" issues I mentioned in a previous post.

Finally, while RDMS will provide you credentialing as a sonographer, at the same level as the techs who perform the exams, the ACR has requirements (but not credentials) to become an "interpreting physician," whether or not you have completed a radiology residency. ACR requires 500 scans and more CME than RDMS, however their requirements are the most strict, if you want to make sure noone can question your qualifications. I linked to their guidelines in a previous post. Either path would ostensibly make you "qualified" to bill to 3rd party payors and medicare.

 

[lawmd]

I designed an EM US elective for December of my M4 year. I got to spend time at the local community college US program doing exams with the people who actually do them in the hospital. I read the US book by John Ma, spent some time up in the anatomy lab, obtained 40 images, reviewed them with a radiologist, and still was able to get 9 interviews out of the way. I would highly recommend this to all M4 doing EM. I will paste the guidelines I came up with. It was easy to start up. Let me know and I can comment more on it.



Ultrasonography in the Emergency Department
A Medical Student Elective
East Carolina University


Introduction:
The use of ultrasound (US) in the Emergency Department (ED) has gained acceptance as a fast, reliable, cost-effective, and non-invasive means for diagnosis of many conditions. Most medical students do not gain much exposure to US imaging during their preclinical years and limited exposure during the clinical years. A dedicated US elective can introduce students to this modality, US technology, its uses, and can serve as an excellent refresher for clinical anatomy.

Duration:
2-4 weeks

Eligibility:
Any 4th year medical student interested in Emergency Medicine

Course Design:
-The student is to be supervised by a faculty member with an interest in US
-An Emergency US book (ex-Emergency Ultrasound by John Ma) should be used to become familiar with concepts and terminology
-The student will spend time at the local community college with US Technology students and practicing exams and learning about the US machine
-The student will then perform US exams on patients in the ED. Exams should focus on the FAST Trauma exam, AAA, and right upper quadrant. The student will also perform exams on patients without pathology
-A total of 40 clinical images should be obtained. Ten of these should include pathology.
-The images will be reviewed by the faculty member or a radiologist