Denying Payments for Musculoskeletal Ultrasound: How Did We Get Here?

OPINION

Denying Payments for Musculoskeletal Ultrasound: How Did We Get Here? Levon N. Nazarian, MD, Archie A. Alexander, MD, JD, LLM A recent policy change at Blue Cross Blue Shield (BCBS) for Texas, Illinois, New Mexico, and Oklahoma regarding musculoskeletal (MSK) ultrasound illustrates how the status of reimbursement for diagnostic imaging can change overnight. On September 1, 2009, BCBS issued its policy “Non-Operative Spinal and Musculoskeletal Ultrasound” (RAD602.016), which deems all MSK ultrasound studies “experimental.” Health care providers who perform MSK ultrasound found themselves denied Current Procedural Terminology® code 76880 and other codes for billing and reimbursement for MSK ultrasound. This change sent shock waves throughout a variety of medical communities, ranging from radiology to podiatry. A variety of sources, including ourselves, the American Institute of Ultrasound in Medicine, and other organizations and health care providers, sent letters to BCBS asking them to correct what was perceived as an obvious mistake. We are happy to report that Allan Chernov, MD, the medical director of Blue Shield of Texas, and the staff of BCBS revisited this issue and restored the original policy on February 1, 2010. The evaluation of MSK ultrasound remains ongoing, which means, as Yogi Berra said, that “it ain’t over till it’s over.” Certainly we applaud Dr Chernov and others at BCBS for listening to reason, but some of us are still asking ourselves (as David Byrne did in the Talking Heads song “Once in a Lifetime”), “How did we get here?” This question is one all diagnostic imagers, radiologists and nonra-

diologists alike, must ponder, because we will face more policy turnabouts by health plans in the future as health care budgets get tighter. Not only is BCBS continuing to monitor MSK ultrasound, but MSK ultrasound is also highly likely to draw increasing scrutiny by other public and private health plans. In reality, MSK ultrasound services are no different from other physician services that are drawing fire from a variety of policymakers who want to control overutilization and its costs [1]. Determining how we got here for BCBS begins with a review of its policy documents starting in 1998. At that time, the chiropractic community and others were claiming that they used paraspinal ultrasound to identify and evaluate significant pathologies affecting the adult spine. Skepticism about these claims led our radiology department to do a clinical research study in which we used 4 independent reviewers to try to identify pathologies on paraspinal ultrasound examinations. The results not only showed a lack of correlation between the 4 readers and their determinations, but one of the readers would have actually performed better by random guessing [2]. On the basis of that article, the ACR [3] and American Institute of Ultrasound in Medicine [4] promulgated policy statements declaring that in adults, paraspinal ultrasound should be considered experimental only. Blue Cross Blue Shield adopted similar policies for nonoperative diagnostic spinal ultrasound in adults on the basis of its lack of scientific documentation of the efficacy of paraspinal ultrasound in adults (Med-

© 2010 American College of Radiology 0091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2010.03.009

ical Policy 6.01.024, originally approved April 1, 1998). Certainly this policy was consistent with the literature, and BCBS gave no hint that it was reviewing MSK ultrasound generally. The silence of BCBS on MSK ultrasound seems prudent because the literature on MSK ultrasound was growing from the first publications in 1984 [5]. Over the past two decades, hundreds of peer-reviewed articles have shown the utility of MSK ultrasound as a viable complement or alternative to the more expensive MSK studies, such as MRI [6]. Reason dictates that BCBS and other health plans should champion the use of MSK ultrasound as a less expensive, but effective, substitute for more expensive studies such as MRI. For example, a recent meta-analysis showed that ultrasound and MRI are comparable in detecting rotator cuff tears [7], and it follows that health care plans could substantially reduce their costs by advocating the substitution of ultrasound for MRI when indicated [8]. In fact, patients even prefer the less expensive shoulder ultrasound to the more expensive MRI [9]. It seems that policies favoring MSK ultrasound would be a “nobrainer” for BCBS and other health plans. So, how did BCBS come to its policy decision to classify MSK ultrasound as experimental on September 1, 2009? In its policy statement of September 1, 2009, BCBS cited its policy on diagnostic spinal sonography in adults and tried to extrapolate it to MSK ultrasound in general. Blue Cross Blue Shield supported its observations with a synopsis of 3 arti553

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cles [10-12]. These articles focus on the role of ultrasound contrast applications in MSK imaging [10], power Doppler applications in MSK ultrasound [11], and training experiences of Irish rheumatologists in MSK ultrasound in Belfast [12]. We understand why BCBS reached similar conclusions as the first two articles designated ultrasound flow studies as experimental until more definitive studies become available. However, BCBS seemed to use the conclusions of the third article to support the proposition that for MSK ultrasound, there is no consensus as yet with regard to the standards required to achieve a basic level of competence in the use of this imaging technique . . . . The development of recognized training programs and international standards of competency are important goals on the way to achieving more widespread acceptance of [MSK ultrasound] as a useful tool in everyday clinical practice.

We do not believe that the experiences of Taggart et al [12] regarding rheumatologists in Belfast are necessarily generalizable to MSK ultrasound in the United States. Moreover, the experience of Taggart et al with MSK ultrasound may actually represent a success story whereby the authors achieved competence through education and training obtained from rheumatologists in other nations as well as assistance from other disciplines such as radiology. Surely, these articles cannot be the true reasons BCBS declared MSK ultrasound experimental. On the basis of our reading of its policy of September 1, 2009, we believe that the driving force for the policy shift lies in the observation by BCBS that there is (1) “proliferation of diagnostic ultrasound units,” (2) for “use by individuals without proper training,” (3) “under conditions of inadequate control,” and that (4) “imaging of superficial soft tissue structures is not yet widely

practiced by the general medical community in the United States”. Blue Cross Blue Shield likely recognized that MSK ultrasound is extremely attractive to nonradiologists, both physicians and nonphysicians, who previously were only minor players in cross-sectional imaging. The wide availability of highquality, low-cost ultrasound units, especially compact units, has enabled the dissemination of ultrasound technology throughout office practices, sports training facilities, and other nontraditional locations. Some believe that the rate of expansion is so rapid that physicians may be participating in a diagnostic imaging “arms race” [13]. Likewise, the utilization of MSK ultrasound is growing dramatically, and much of this growth may be due to self-referral. We may debate the merits of self-referral for patient care, but the reality is that physicians perform more tests when they self-refer [14,15]. This reality is not lost on policymakers, who believe that many physicians simply provide more services to subsidize their sagging incomes [13,16-18]. Many of our colleagues in diagnostic radiology are reluctant to embrace MSK ultrasound for a variety of reasons [2]. Nature abhors a vacuum, and the unwillingness of most radiologists to adopt MSK ultrasound has left the door open for other specialties. Must we fault the nonradiology specialties for creating new service lines to extend services we cannot or will not provide? The bottom line is that the proliferation of new service lines and technology causes the overutilization of services and drives up the overall cost of health care [13]. This phenomenon is not lost on policymakers, employers, payers, and consumers, who see the creation of new service lines and the expansion of diagnostic imaging services as one more threat to their economic stability. Imaging ser-

vices are now on the list of reasons for our high health care costs, which includes administrative inefficiencies, medical errors, medical liability claims, and health insurance deficiencies. The public just wants reduced health care costs and does not care whether demand for diagnostic imaging services, including MSK ultrasound, is driven by radiologists, nonradiologists, or consumers. To help control costs, policymakers are looking to limit access to diagnostic imaging services through a variety of regulatory mechanisms, such as (1) changing our existing reimbursement scheme from fee-for-service to value-based alternatives, (2) requiring more credentialing and accreditation to limit entry or access of physicians to imaging, (3) training more primary care physicians who tend to order fewer tests, and (4) using health IT to monitor utilization and quality [19-21]. If we read between the lines of the September 1, 2009 policy, we believe that BCBS saw a marked proliferation of MSK ultrasound and felt that it had to control costs by declaring MSK ultrasound experimental and trying to portray the aforementioned articles as supporting that position. The obvious countervailing argument is that BCBS and other payers could save money when physicians use MSK ultrasound as a substitute for more expensive studies such as MSK MRI [8]. Unfortunately, this cost reduction counterargument fails when we consider the explosive growth in the number of MSK ultrasound studies fueled largely by self-referral. In fact, our imperfect methods of tracking the clinical effectiveness and quality of imaging make it difficult for us, health plans such as BCBS, or policymakers to know the true value of diagnostic imaging services such as MSK ultrasound [22,23]. There-

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fore, any data we present for or against the use of diagnostic imaging technology cannot be verified in most cases. Because BCBS could not distinguish who should and should not get paid for MSK ultrasound on the basis of its clinical effectiveness or quality, the easiest response is to stop paying for code 76880 altogether. Fortunately, BCBS listened to reason this time. What can we do in the meantime? Plenty! For one thing, we must begin looking critically at policy determinations by health plans to make sure studies and data support their decisions. We must be prepared to support our professional associations when we are asked to write letters and make calls. Likewise, we must be willing to work with all health care stakeholders, whoever they are, so we can reach sensible policies on our health care resources, especially diagnostic imaging services such as MSK ultrasound. After all, our world of diagnostic imaging is becoming more like Garnett Hardin’s [24] tragedy of the commons, as more nonradiologists put imaging systems in their offices [19,25-28]. Unless we figure out how to control our collective overutilization of diagnostic imaging services, we may suffer the same fate as the greedy English farmers who so overgraze their commons that they ruin it for everyone. We must help our policymakers craft laws and regulations that enable us to manage our resources prudently without limiting access to needed services. Otherwise, we may be paving the way toward rationing or other limitations on our health care resources. We must push ahead with accreditation programs for MSK ultrasound as well as other diagnostic imaging services. Accreditation would ensure a minimal standard for

quality, give health plans and other payers criteria on which to base reimbursement, and help control imaging overutilization. More important, our various medical associations and societies may have to adopt common sets of credentialing criteria to make sure that those wishing to provide these services are qualified. Many such criteria are in place, but compliance is usually voluntary and thus not universal. We must move forward with our adoption of health IT while adopting laws and regulations that promote the secure exchange of health information. Without these measures, we will have no way to access or compare the quality of the delivery of services intelligently. With these measures, we may be able to construct reins and fences that allow a variety of professionals to provide diagnostic imaging services while assuring patients that they are getting quality and value they deserve. If we neglect these important issues, we may find ourselves, like David Byrne, wondering, “How did we get here?” when health care plans begin changing their payment policies to curb imaging overutilization. REFERENCES 1. Miller ME. MedPAC recommendations on imaging services. Available at: http://www. medpac.gov/publications/congressional_ testimony/031705_TestimonyImaging-Hou. pdf. Accessed February 28, 2010. 2. Nazarian LN, Zegel HG, Gilbert KR, Edell SL, Bakst BM, Goldberg BB. Paraspinal ultrasonography: lack of utility in evaluating patients with cervical and/or lumbar back pain. J Ultrasound Med 1998;17:117-22. 3. American College of Radiology. Statement on spinal ultrasound. Reston, Va: American College of Radiology; 1996. 4. American Institute of Ultrasound in Medicine. Nonoperative spinal/paraspinal ultrasound in adults. Official statements. Laurel, Md: American Institute of Ultrasound in Medicine; 1995. 5. Dillehay GL, Deschler T, Rogers LF, Neiman HL, Hendrix RW. The ultrasono-

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Levon N. Nazarian, MD, is from the Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Archie A. Alexander, MD, JD, LLM, is a health law, policy and bioethics attorney and mediator in Austin, Texas. Levon N. Nazarian, MD, Thomas Jefferson University Hospital, Department of Radiology, 132 South 10th Street, Room 763E Main Building, Philadelphia, PA 19107-5244; e-mail: [email protected].