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JASE Article-Echocardiography Training-Live
pererap
Posted: Sunday, June 9, 2013
Joined: 8/31/2011
Posts: 231


Greetings,

Some of you may have seen this editorial in the April 2013 JASE but I suspect many of you have not.

In 2010, ACEP collaborated with the ASE to publish a consensus statement on the use of cardiac ultrasound in the emergent setting.

This new article, written by many of the same authors, basically stabs us in the back and offers a clear mischaracterization of focused cardiac ultrasound

It is important to note among many other disturbing things in this article, the repetitive description of focused cardiac ultrasound as an "adjunct" or "extension" of the physical exam

I want to assure all of you that section leadership is working hard on a response to this editorial and the ACEP board is also aware.

We will fight for what we believe in and come out on top as we always have.   I think we can all agree at the end of the day we are the only ones that truly care for the patient in this equation.  


I have attached the 2 documents below for your reading pleasure.  


I will keep you posted.

Have a great rest of the weekend.



RG

 

Rajesh Geria MD RDMS FACEP
Chief, Division Emergency & Critical Care Ultrasound
Assistant Professor
Chair ACEP Emergency Ultrasound  Section
Director, Ultrasound Fellowship
Department of Emergency Medicine
Robert Wood Johnson Medical School
New Brunswick


pererap
Posted: Sunday, June 9, 2013
Joined: 8/31/2011
Posts: 231


Greetings to all,

just a short comment from Europe on this USA dispute. I read the article and I sincerely think that the philosophy of the emergency physicians is totally different from cardiologists and radiologists. In my modest opinion, the effort that should be done is to make accept our point of view on the use of US as an extension of the physical examination. We should not make the error to follow the principles of consultative US. As such, I am convinced that the only credentialing for emergency poc US is the practice of emergency medicine. Do we need credentialing to use the stethoscope other than our degree and specialty? The same should be for poc US. If we follow the cardiologists and the radiologists and try to fix the number of examinations, who are the experts and so on, we will never find the key of the problem and will not differentiate poc US from consultative US.

Giovanni Volpicelli, MD, FCCP
Department of Emergency Medicine
San Luigi Gonzaga University Hospital
Torino, Italy
pererap
Posted: Sunday, June 9, 2013
Joined: 8/31/2011
Posts: 231


Out in rural Montana in the USA, we agree with Dr Volpicelli.  Ultrasound should be an extension of the physical exam, and not require separate credentialing.  As I am sure we will recall from history, the stethoscope itself was not at first embraced by many physicians, and for quite some time nurses were not supposed to use them!  It seems silly now, but such concerns plague the adoption of point-of-care ultrasound exactly.  I am just a rural EM doc, working in the same little community for 23 years. I don't usually speak up, nor should I.  Here in our little town we are not on the forefront of change and I am privileged to read and learn here.  But this wonderful comment by Dr Volpicelli just had to have my little voice of support.
Thank you so much.
 
Cameron Parham, MD
Emergency Dept
Northern Montana Hospital
Havre, MT, USA
pererap
Posted: Sunday, June 9, 2013
Joined: 8/31/2011
Posts: 231


The difficulty currently with calling it an extension of the physical exam is with reimbursement.  I do believe we should continue to assert that the value EM provides is that ability to perform focused history and physicals, and that the use of ultrasound for diagnosis or procedure adds significant value to the patient.  The fact that we are doing the ultrasound contemporaneous to the H and P makes us different and allows for earlier diagnosis and treatment.

 
William Jaquis, MD, FACEP
Chief, Department of Emergency Medicine
Sinai Hospital of Baltimore
wjaquis@lifebridgehealth.org
(410) 601-5737


pererap
Posted: Sunday, June 9, 2013
Joined: 8/31/2011
Posts: 231


I wonder if we just have to give up the extra reimbursement if we are going to assert that it's a part of our physical exam. We wouldn't think we should charge extra for our use of the stethoscope.  I know that here the comparison wears thin right now, since the equipment for ultrasound costs so much more than a stethoscope, and it does require extra training. Yet if we want the freedom to wield this tool to be fully in our hands we may have to do that.  By hoping for reimbursement we inherently allow others to  make decisions to limit us, since third-party payors thus have an investment in the decisions. I'd wonder if we should just consider it 'value added' to our exam. Take the payors' hands out of the cookie jar by letting the cookies go for free.  Just a thought.  I am sure I cannot know all the various repercussions.
Cameron Parham, MD
Emergency Dept
Northern Montana Hospital
Havre, MT, USA
pererap
Posted: Sunday, June 9, 2013
Joined: 8/31/2011
Posts: 231


Speaking for myself and my understanding of the concerns of my Emergency Medicine colleagues in the United in various settings (rural, suburban, and urban), I would make the following comments about US as an extension of the physical examination in the United States..
 
Ultrasound may be complementary to the physical examination, but has its own science and knowledge
The physical examination has its own art and science, and has its own meaning   Confusing the US findings and physical exam findings sometimes leads to more confusion.
If you want to use US as part of the physical exam, just do it.  I doubt anyone will stop you, and if it helps you and your patients, that is great.
However, when you use US to say “there is hemoperitoneum,”, “ there is tamponade, “   there is “pneumothorax”  “ there is an ectopic pregnancy”, “there is an abscess”, and the next thing some medical professional does is an invasive procedure, or you go down another diagnostic route,  we who use US have a responsibility to make sure 1) we are doing correctly, 2) safely, 3) communicate our findings, and 4) take responsibility for our US skills and interpretation.
I agree with our leaders that calling US an extension of the physical exam does a disservice to the science and field of emergency ultrasonography.
 
In regards to the differences in the United States
1. In the United States, as opposed to other areas of the world, we have a dysfunctional system that puts a heavy burden on the emergency department and emergency physicians.
2. We emergency physicians are asked to do a lot of work that encompasses the span of medicine. Ultrasound is work, though enjoyable.  As physicians in America, we need acknowledgement regarding the time, work and cost of ultrasonography in the evaluation of the patient.
3. In addition, nothing is free in healthcare systems.  Ultrasound systems cost money, and most hospital systems are very strapped for money these days. American hospitals are reluctant to fund equipment despite the benefits of ultrasound, if US is just perceived as a “cost.”
4. When payors and the public hears “ US in an extension of the physical exam”, they logically think they paid for the physical exam, and do not need a separate charge for the US.
5. Regardless if you believe in charging for your US, I do think you want credit for the work of the US, and in the United States, that means a code and documentation.
6. There are other implications to making sure we code for our ultrasounds, and the physical examination analogy does not help us.
 
 
Regarding going down the path of consultative US:
We work within the system that we have, and the politics of health care is very difficult.
New codes for our type of ultrasound would be nice but a tremendous of work without an assured outcome that would help us at this point. We will see if the atmosphere changes with the use of bundled payments and ACOs.
Certainly as we move forward, US will become a core skill in emergency medicine, and may not need separate credentialing. But for the foreseeable future, it continues to be a skill that is challenged by credentialing committees, other physicians, and payors.
 
I am dismayed by the ASE article, especially because I worked with some of the cardiology authors on the joint ASE-ACEP article for 2 years, and I felt we had developed an understanding and respect for each other’s work. Clearly, their article dismisses how valuable our use of US is, and challenges any future endeavor with the ASE.   
 
 
VST
 
Vivek Tayal, MD, FACEP
Director, Division of Emergency Ultrasound
Past Chair, ACEP Emergency Ultrasound Section
Professor of Emergency Medicine
Department of Emergency Medicine
Carolinas Medical Center – Main
704-355-3181
vtayal@carolinas.org

pererap
Posted: Sunday, June 9, 2013
Joined: 8/31/2011
Posts: 231


I also have to disagree with you Cameron.
Since the beginning, physician-performed ultrasound has been considered a diagnostic imaging modality (supplementing the actual physical exam with additional information). I don't see that this has changed.
What changed? Ultrasound's portability (and in some parts of the developed world its accessibility).  

Put another way: Should we now expect that a pulmonologist considers a bronchoscopy an extension of their physical exam?  How about an echo for the cardiologist?  


Regards,
Beatrice

Beatrice Hoffmann, M.D. PhD. RDMS
Ultrasound and Fellowship Director
Beth Israel Deakoness / HAEMR
Harvard Medical Faculty Physicians


pererap
Posted: Sunday, June 9, 2013
Joined: 8/31/2011
Posts: 231


The core of the JASE piece is that for cardiologists cpt 93308 is fine for anything they do while billing for 'FCU' should be "None".

In an ideal world we would all do echo (US) whenever it might benefit our patients if the equipment and expertise were available. However, in the US right now, without specific reimbursement it is unlikely that this would be widely true (or trending towards true) in most EDs.

Reimbursement has led to the 100+ EM fellowsips in ultrasound on the US. These fellowships have pushed the envelope on what EUS is, which has spread around the world.

Reimbursement has allowed for equipment, expertise, and QA systems that have raised the bar in what emergency care is, and has no doubt saved lives.

Fee for service in the United States has huge issues, but if we are investing in the training, QA, and equipment in a 24/7/365 setting where we can provide a potentially life saving diagnosis and therapy, we should be reimbursed as equitably as our colleagues who are in much less time sensitive situations.

The use of ultrasound is far more complex and potential impact far more extensive than the stethescope ever was or is.

Until fee for service is reformed we need to fight for appropriate reimbursement for what we have invested the time and effort to do right.

Sincerely,
Chris Moore
zolopang@hotmail.com
Posted: Monday, June 10, 2013
Joined: 4/18/2011
Posts: 2


To All: (sorry this hit the listserve...)

I do not usually respond to these messages, but I feel there are certain members of this group that need convincing of two major points: (I gave up trying to be humble - forgive me)
 
1. Ultrasound is both a technical and knowledge based skill, and NOT part of the physical exam. Simply put, the information gained is electronically generated: not directly seen, heard, smelt, felt, or god forbid, tasted (remember - physicans used to taste urine for DM). A stethascope is a glorified amplifier, not a complex machine. Furthermore, the skills and knowlege base are completely DIFFERENT from those of a phycial exam. Because they can be used together for clinical decision making does not mean they are the same exam.
 
This can be said regardless of whether or not we get reimbursed. however...
 
2. Reimbursement for time spent using this technology should be aggresively pursued - as we spend the same time and use the same skill as other POC or US providers. Should we not get paid for doing central lines? Intubating? It is a skill/procedure that is separate from other skills performed at the bedside (see point #1), and should be reimbursed as such. This reimbursement supports the ability to maintain effective EUS programs, either community or academic. The time and equipment just ain't free...
 
Anecdotaly:
 
I am a community ED doc in Long Island with EUS fellowship training. I currently do not get reimbursed for my ultrasounds despite appropriate documentaion and review processes. (Internal hospital issues)
 
About 1/3rd of our ED Doc's use EUS - and ALL come from ED programs with EUS fellowships.
 
Convincing my other partners to upgrade their skills should not require more money. But in the real world, as an US novice, they can see another patient in the time it takes to perform and document an ultrasound, and get paid more...
 
If I was able to reimburse for US use, that would be ONE LESS in a series of barriers to get my partners to use the machine, and start saving patients.
 
Getting more experinced practitioners to pick up, use, and become proficient in this skill is, in my mind, our single bigggest challange as a group.
 
Getting our community to be COMPLETELY UNIFIED when it comes to the DEFINITION of EUS is CRITICAL for this step, as is the need to pursue reimbursement. To skip this just to have the opportunity to use the machine is, in my humble opinion, not they way to go. We would win the battle but loose the war. Reimbursement is KEY because it DOES support the proper training, use, and monitoring of EUS. Without these - we run the risk of being sloppy... and if we make mistakes - no more using the machine. I could care less wht ends up in my pocket.
 
I belive it is critical for us to all have the same opinion about what EUS is and why we should be reimbursed, as we all talk to each other and to our respective consultants in the ED, and hopital administrators and systems. The foundation has been laid out for this - we now have to build it, and not in a rapid, sloppy, easy way. If it was easy it wouldn't be worth it.
 
This technology is VITAL to the practice of Emergency Medicine, and I really applaud the efforts and the sacrifices of those who have worked, and continue to work, a lifetime to make this happen - both the education/reasearch and reimbursement pieces. 
 
The number of lives saved and procedural complications avoided is incredibly dramatic. We have to keep moving forward. 

Sincerely,
 
Mike Z

Michael Zimmerman, MD

 


pererap
Posted: Monday, June 10, 2013
Joined: 8/31/2011
Posts: 231


I am so appreciative to have been included in this debate, and I have been convinced by the articulate and passionate defense of reimbursement in the current system in the USA, and why it should for now remain a separate diagnostic procedure.   In rural Montana for a while longer at least I won't be reimbursed.  Here we are still such novices, and we must justify our diagnoses and consult requests by more traditional means.  But I am convinced.   Again, I am grateful for the answers and to have been included. 
 
Cameron Parham, MD
Emergency Dept
Northern Montana Hospital
Havre, MT USA
pererap
Posted: Monday, June 10, 2013
Joined: 8/31/2011
Posts: 231


Wonderful discussion. Many in the section have taught, promoted, defended and lobbied for ultrasound be it clinician performed, focused, limited, POC ( however you define it with ACEP criteria) to be both reimbursed and defined as a value added , distinct diagnostic  modality.

As we have really only scratched the surface of the technology in clinical arenas lets look at one other compelling argument to have this modality reimbursed and billed.

As HC reform moves forward CMS has two ways right now to tally the impact of our use of the technology. Research on their population (large granted and cohort studies) or database runs. The only way to register that an ED US was performed is to have that study billed and registered use in the claims based data that CMS and its contractors, Lewin, Mathematica and others use.

If we do not bill, the assumption is that it never happened, from a claims based population approach that CMS uses. Here in the USA, we need to do it, document it, retain it, own it, an bill it! 

Paul R. Sierzenski, MD, RDMS, FACEP
Councilor ACEP US Section Rep.
Chair ACEP US Sec. Gov. Policy
Dir. EM, Trauma, & CC Ultrasound
Dept. of Emergency Medicine
Christiana Care Health System
c: 302.540.3621
o: 302.733.1630
pererap
Posted: Tuesday, June 11, 2013
Joined: 8/31/2011
Posts: 231


A 29-year-old female is dropped off at the doors of the emergency department and her husband heads to the parking lot to park the car. The woman who looks quite pale and diaphoretic is guided by triage back toward awaiting emergency department room. As I am standing in the door, she collapses to the floor just outside the door. I rush out and check a pulse and find none. We quickly drag her up to a gurney and start CPR. Bag valve mask breathing ensues as well. Thankfully, the code cart is right outside and a paramedic standing by places an IO in the tibia and gives epi. The patient is being adequately ventilated at the moment with bag valve mask. While CPR is in progress, I drag in the ultrasound machine and quickly note large hemoperitoneum and a complex left pelvic mass. Two minutes up and check for cardiac activity. Good strong pulse and a call to ob-gyn. What? You want an hcg? Whatever, get down here and we'll get one(maybe)! Intubate, cordis placed by us guidance and o neg going in. 12 min passed. Ob-gyn is here and heading to surgery in 20 min after cardiac arrest. Oh yeah, hcg positive. 
Do that without ER physician bedside ultrasound. 
Sounds like a pretty good value to me. 
Didn't even need a ct scan(cause we don't really scan everybody) and apparently they don't really want us to do those as much either. 
Yep, it is really pretty obvious that this ability adds quality care and cost savings in the long run. Especially as we approach utilization review issues. 
Thanks
Scott Holliday DO, FACEP
St Luke's Regional Medical Center
Twin, Falls, Idaho 

pererap
Posted: Sunday, June 30, 2013
Joined: 8/31/2011
Posts: 231


Hi all,
 
In light of recent discussion about the ASE article thought people might be interested to hear about the ASE annual meeting in Minneapolis this weekend.
 
Dr. Vicki Noble and I were invited to speak (prior to the 2013 article), and we participated in two sessions on "Point-of-care", one more didactic and one live scanning session, I believe we were the only EPs there.
 
The ASE speakers appeared to work in concert to further the effort of the ASE article to equate "point-of-care" with "FOCUS", "focused", "hand-held", "pocket-carried", etc. as distinct from "limited", which they are attempting to define as a study done by an "echocardiographer" (i.e. "highly trained", ASE level II/III) with a reasonably high capability machine that is more limited in scope than a "complete" echo.
 
The reason for this is clear - they are afraid that with the spread of pocket carried equipment if anyone who obtains one of these and takes a look at anyone (in the office, the hospital, the emergency department) and bills a "limited" code, that this code will be diluted to the point of being irrelevant.
 
Vicki and I took pains to point out that most of us in emergency medicine are using equipment that is cart based, have more probes and capabilities than a pocket carried machine; we are doing studies at all hours in potentially life threatening conditions; and we have a long history of doing echo to save lives (Vicki cited Plummer 1992) as well as having invested in QA, archival, and integration into our training programs that is now required by the ACGME for emergency medicine residency accreditation – all of which meets the limited CPT coding guidelines as well.
 
On a positive note, there seemed to be widespread agreement that the use of echo in the emergency situation can be crucial and even life-saving, and no one is questioning our use of this technology.
 
This will undoubtedly be an ongoing discussion, but I think it is important that in the current climate we continue to emphasize these points that make cardiac ultrasound as performed by emergency physicians distinct from routine or serial assessment/ screening exams using a pocket-carried device.
 
Hope everyone is having an enjoyable summer,
 
Chris




Christopher L. Moore
Associate Professor, Department of Emergency Medicine
Yale University School of Medicine
chris.moore@yale.edu


pererap
Posted: Tuesday, July 2, 2013
Joined: 8/31/2011
Posts: 231


It is worth noting that at the AMA House of Delegates meeting last month in Chicago, the council on radiology beat the same drum. This is a body made up of all radiology groups and societies. They clearly want to separate out our ultrasound examinations as part of the physical exam and non reimbursable. They also acknowledged that ultrasound helps save lives and improves procedure guidance. Their biggest concern was the training "of all of these new users with small machines" "who would walk around scanning everyone". The result would be "a shrinking pie, being divided even further".

It seems the stars are aligning against us at this time.

Mike Blaivas


pererap
Posted: Saturday, July 6, 2013
Joined: 8/31/2011
Posts: 231


Chris, Thank you for the update. I fully support both your sentiment and your statement "I think it is important that in the current climate we continue to emphasize these points that make cardiac ultrasound as performed by emergency physicians distinct from routine or serial assessment/screening exams using a pocket-carried device."

    Colleagues,   Admittedly I have edited and tweaked this email several times with one primary goal; my hope is to persuade you that given the history of the politics of emergency ultrasound, and in light of the recent ASE and ACR developments, that the reference to emergency ultrasound (clinician performed sonography, POCUS etc.) with terms such as "extension of the physical exam, stethoscope of the future, quick look", are truly detrimental to the defined intended use in emergency medicine and the distinction that Dr. Moore discussed. Though these terms are of great value from an education and medical school integration aspect, longitudinally these do not describe what ACEP doctrine details, and ultimately devalues what we do respective to work effort, reporting effort and the value of the technology. They blur the distinctions that we need to make with our ED performance of cardiac ultrasound.

    These terms bolster the argument that ASE, ACR and insurers use, who argue that the technology is valuable but should not be reimbursed.  Back in the day, Mike and I attended one of the first AIUM POCUS Forums and we explained in detail how ANY imaging study, post evaluation could be argued to be an "extension" (I realize with bundled care that may be our destiny, but lets not catalyze it). We provided examples of MRI in stroke, CTA for suspected PE , etc.  The then President of AIUM  (Beryl Benacerraf) stood up and stated that the use of the term "extension of the physical exam was dangerous terminology, and should be struck from use."  

    As Chris has very well detailed, we must differentiate what we (and ACEP policy defines) commonly do in the ED, with what is frequently performed by others when using "pocket ultrasound".  However, I don't think we should make this about the technology, as technology progresses every day. The discussion should be about "work effort and work product" (indication, performance, image archiving and reporting).

     For almost 15 years now, I and others have lobbied, on behalf of ACEP, to specialty societies, CMS, and private payers that "Emergency Ultrasound / Clinical Sonology is a focused diagnostic test that when clinically indicated, archived and reported, should be reimbursed for patient care, work effort and work product." As such, it is not an extension of the physical exam.

    Now what about the attempt to redefine the aspects of  "limited echocardiography; CPT 93308" as argued by ASE, that our focused use does not meet that definition. The ASE is absolutely incorrect and misleading.  I will be posting again on this related to what CPT and what the AMA RUC states, and how wrong the recent ASE authors actually are based on the definitions.  Neither ASE, not ACR should get to unilaterally redefine CPT or the American Medical Association/Specialty Society Relative Value Scale Update Committee RUC conclusions.  However as Mike noted, the ACR is attempting to lobby the AMA to do change the game. The ACR, maybe the ASE and others may try to redefine Emergency Ultrasound or exclude it from valuation via the AMA RUC. This is why ACEP is so active in AMA and the AMA/RUC and why membership and monitoring of the AMA is critical.

    On a less defensive front, I feel EM and all clinical specialties should address the issue of inappropriate and unnecessary use of the "complete codes" that many of the consultative studies ordered and performed in hospitals bill. These often go far beyond what is diagnostically necessary, increase costs and ultimately could be modulated through a "step-wise, staged, or progressive" imaging pathway.  The CMS coverage sections likes this concept where appropriate (e.g.. RUQ pain, echocardiography , etc.)  Does everyone need a "complete echo, complete abdomen etc?"  

    Dr. Geria, in collaboration with others, is addressing this issue in the house of medicine to further define the value of clinician performed ultrasound in a favorable light and distancing the terms (extension of the physician exam, etc.) I have discussed.

    Please read the policy statement below. It clearly demonstrates the negative unintended consequences of the terms I and others have raised concerns about for years. I do not think any of us would like to see emergency ultrasound in any form subjugated to be an unfunded mandate.

Thanks for your attention and consideration,

Paul

Paul R. Sierzenski, MD, RDMS, FAAEM, FACEP
Chair, Government Policy & Public Relations.  ACEP Ultrasound Section
Director Emergency, Trauma & Critical Care Ultrasound
Department of Emergency Medicine
Christiana Care Health System
Newark/Wilmington Delaware
pererap
Posted: Friday, August 2, 2013
Joined: 8/31/2011
Posts: 231


Greetings,


We responded to the ASE in the form of a letter to the president last week

Highlights of that letter were as follows:

Reminded them of our collaborative document in 2010 and how this new document contradicted everything we accomplished
Expressed concern that this will negatively impact patient care going forward
Summarized RUC/ CPT criteria for billing: indication, image retention, and report generation
Described technology as dynamic and continuously evolving and that reimbursement should occur regardless of technology as long as RUC/CPT criteria followed
Strongly condemned the terms eFCU and FCU as being made up for the sole purpose of protecting the cardiologist from being diluted amongst other specialties and that these terms do NOT account for the value limited echo adds to the patient evaluation when performed by appropriately trained physicians
Made them aware that the editorial written by ASE Dr. Hahn where she stated "  ASE has an obligation to partner with other societies and participate in the development of non traditional user guidelines, as well as the development of educational programs" was contrary to the AMA 802 document which clearly states that imaging is within the scope of appropriately trained physicians and that training and education standards  are to be developed by each physician's respective specialty.  
Stated that ACEP would appreciative a collaborative discussion with the ASE on areas of mutual interest  and would hope in the future when these issues are raised, ACEP's emergency ultrasound leaders are involved to promote the highest quality of care to our patients


We have since received a response from their president admitting that the JASE article has caused a lot of unintended consequences and that they agree with many of our points.  He also stated that the ASE supports the use of cardiac ultrasound by a wide variety of practitioners as a powerful tool in the management of patients in many clinical settings including the Emergency Department.  He admitted that sometimes an unfavorable situation can become an opportunity for a new stronger collaboration.  


Face to face meetings between our organizations to discuss these issues in detail will ensure in the next few months and I will have further updates at the section meeting .


Never a dull moment !!



Have a great weekend

RG





Rajesh Geria MD, RDMS, FACEP
Chief, Division of Emergency & Critical Care Ultrasound
Assistant Professor, Staff Attending Physician
Chair, ACEP Section of Emergency Ultrasound

 
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