Why you should care about billing for your scans
An uncomfortable subject for physicians but billing for our services is not just about compensation it is also recognition of the training, expertise, and time involved in providing a service. But most importantly, compensation for POCUS is necessary for its long term viability.
Join the dark side, but watch your gain!
The initial battle was all about fighting for our right to perform bedside ultrasound. Most of the early adopters put remuneration on the back burner while they overcame political, legal, and logistical obstacles. They did it because they saw the immediate benefits to their patients.
As I have told numerous students, in my two decades of practice, new skills I learned through CME would result in something I might apply once a week, once a month, maybe once in a career. When I picked up my first probe, I was learning a skill I would use every single shift, on the majority of my patients. A real career game-changer. Payment was of a far lesser priority than mastering a skill that made such a difference.
As POCUS matures, we have a growing body of literature demonstrating its efficacy in care, but also significant cost savings to the system. Yet most of us are not remunerated anywhere close to what this service is worth. Even more insulting, some specialities are eligible to receive a greater payment for the performing the exact same scan.
The American College of Emergency Physicians released a statement this summer summarizing their stance:
“Emergency physician use of ultrasonography provides timely and cost-efficient means to accurately diagnose ED presenting illness and injury to provide higher-quality lower-cost care. ED ultrasonography use can often reduce the need for more expensive studies such as computed tomography or magnetic resonance imaging and reduce unnecessary admissions for more comprehensive diagnostic evaluations. Ultrasonography use in the ED should be appropriately recognized and fairly compensated.”
Approved by the ACEP Board of Directors June 2016
In Canada, like most medical care, emergency physician compensation is primarily based on a single-payer government system. However the method of payment differs by province.
In Ontario, payment for POCUS is either provided at 100% of the provincial fee schedule for departments that work entirely on a fee for service plan, and for the others around 37% in the form of shadow billings where income is based on an hourly rate.
Before you say that doesn’t sound too bad, it should be noted that the fee schedule was modified several years ago to disallow emergency physicians to bill almost all ultrasound codes in schedule. Instead a new diagnostic code was established that pays either $20 or $7 for shadow billers (before current across the board cutbacks). However this code can only be billed on basic scans such as AAA, pericardial effusion, FAST, and detection of 1st TM pregnancy.
Unlike radiology fees, this billing code does not provide any funding for equipment or archiving costs. Many emergency departments have funded some or all of the ultrasound equipment and QA out of their own pockets or through charitable donations. Our physician group pooled its own money to help buy our last three ultrasound machines and obtained donors to help pay the difference. That is no way to fund a sustainable medical service.
Procedure or scan but not both!
The code fails to recognize all the other diagnostic POCUS scans used in shock, abdominal pain, chest pain, etc. In fact, the only other official code that can be used by EP’s is a procedural code that cannot be billed along with the procedure. Thus, performing an ultrasound guided abscess drainage or pleurocentesis means an Ontario physician may only bill for the procedure or the scan. In most cases the procedure pays slightly more, so once again, no remuneration is provided for POCUS.
In Quebec, there is a $20 billing code with several more eligible types of scans. There is a fear this code may be discontinued in the near future as part of cost-cutting measures.
In Saskatchewan and British Columbia, there is no billing for complex skills such as POCUS at all.
The effects of this billing restriction is insidious and potentially catastrophic.
POCUS is under-utilized in fee-for-service departments in all provinces without billing codes as it is perceived to slow the physician down with no remuneration to compensate them for their time. Although experienced POCUS providers find that a greater use of POCUS saves time, the perception is real. This is the biggest danger of our inadequate payment system. The time and cost for practicing physicians to become competent is an even greater barrier when there is no subsequent compensation to apply POCUS. A modality that saves lives, reduces patient hospital stays, and saves the system money, is not being performed because of the inadequate upfront monetary support.
Without funding for physicians or hospitals, administrative aspects of POCUS programs, including quality assurance, are threatened.
There are an insufficient number of machines in most ED’s because of this funding deficit. POCUS cannot be effectively practiced if three physicians on shift are sharing a single system. How often would you use a stethoscope if there was only one to share amongst three or four caregivers?
As more clinicians in various practice settings embrace POCUS, there will be a growing pressure to support providing this service. A remote rural physician who can detect an aortic aneurysm or early heart failure at their clinic and arrange followup before rupture or fulminant pulmonary edema is saving lives and money. This is worth supporting.
There didn’t exist billing codes to support laparoscopic surgery when it took off many years ago, as I was beginning my career. However, recognition of this new procedure and its costs resulted in new fees that make it sustainable. POCUS is a tectonic shift of the same magnitude and deserves more than a token fee code that fails to acknowledge the required training, skills, cost savings, and improved patient care.
We need to advocate for proper funding if we want POCUS to evolve, be performed safely with adequate oversight, and allow the acquisition and maintenance of equipment. It is time for organizations like the Canadian Association of Emergency Physicians to produce a statement of support like ACEP has done.
I would love to hear what current compensation is available where you practice and your thoughts on appropriate remuneration and its effects on POCUS.
Addendum:
For non-Ontario physicians I have attached an excerpt of our POCUS billing code. Note that it can’t be billed if a radiologist is available to perform the scan, despite the fact the cost of their scan is greater. They have also included the bizarre requirement that the ultrasound machine have M-mode, which isn’t even required for any of the billable ED scans.
Emergency department investigative ultrasound
An Emergency Department investigative ultrasound is only eligible for payment when:
- the procedure is personally rendered by an Emergency Department Physician who meets standards for training and experience to render the service;
- a specialist in Diagnostic Radiology is not available to render an urgent interpretation; and
- the procedure is rendered for a patient that is clinically suspected of having at least one of the following life-threatening conditions: pericardial tamponade, cardiac standstill, intraperitoneal hemorrhage associated with trauma, ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy
Payment rules:
1. H100 is limited to two (2) services per patient per day where the second service is rendered as a follow-up to the first service for the same condition(s).
2. Services listed in the Diagnostic Ultrasound section of the Schedule, both technical and professional components are not eligible for payment to any physician when ultrasound images described by H100 are eligible for payment.
Note:
H100 is only eligible for payment when it is rendered using equipment that meets the following minimum technical requirements:
1. Images must be of a quality acceptable to allow a different physician who meets standards for training and experience to render the service to arrive at the same interpretation;
2. Scanning capabilities must include B- and M-mode; and
3. The trans-abdominal probe must be at least 3.5MHz or greater.
Medical record requirements:
The service is only eligible for payment when the Emergency Department investigative ultrasound includes both a permanent record of the image(s) and an interpretative report.
Claims submission instructions:
Claims in excess of two (2) services of H100 per day by the same physician for the same patient should be submitted using the manual review indicator and accompanied by supporting documentation.
[Commentary:
1. See page GP34 for the definition of an “Emergency Department Physician”.
2. Current standards and minimum requirements for training and experience for Emergency Department investigative ultrasound may be found at the Canadian Emergency Ultrasound Society website at the following internet link: http:// www.ceus.ca.]
It is interesting that on all of my older/complicated patients, I routinely scan the CVS (multiple views), LKKS, IVC, JVP, pleura, lungs, aorta, etc. Also scans such as tonsils (for Quinsy), testicles, small bowel, colon, various soft tissues, DVT, pelvic (non-pregnancy), appendix, GB, transcranial, Optic Nerves, etc. Technically none of the above can be billed. And if I do bill it’s H100A or $19.65/3 (APP) as Greg advises.
The procedural code is J149 which is ofter less than the procedural code and cannot even be augmented by E412, E413 after hours (Ontario Billing Codes).
You can also bill G900 for residual bladder volume which is a useful scan for any older male.
I’m still going to provide these scans because they speed patient care. Still it would be nice to have extra codes. Say a Soft Tissue Code for all sorts of exams and maybe a Complex Resuscitation code for ill patients.
If we were sitting in our offices or walk in clinics, we could bill all sorts of exams which Emerg. M.D.’s aren’t allowed.
Soon we’re all going to have our own hand help probes which will link to our smartphones or tablets. These codes would at the very least reimburse us for such equipment not to mention our expertise.
Great article Greg. Nails the issue as I see it here in Allberta. It’s pretty hard to convince physicians to learn and use these skills when doing so only potentially opens them up to extra liability without compensation even if it is better for patients.