Replies to This Discussion

Permalink Reply by Keith Hansen on December 28, 2009 at 2:02pm

Back in 1996 the American College of Radiology came out with a position statement that Non-operative spinal/paraspinal ultrasound in adults was investigational and a non-covered service based on insufficient evidence. The ACR and the AIUM both have position statements that extremity MSK ultrasound is a valid and covered service by all insurances. Only until double-blind, peer-reviewed literature is significantly available will spinal/paraspinal ultrasound be covered. Therefore, don't worry the ultrasound you are performing on the foot will still be covered. You may, though, at some point have to take a test to validate your competency.

Dr. Keith Hansen

Permalink Reply by desiree lerro, d.o. on December 28, 2009 at 3:02pm

for the time being, you may try to bill as "soft tissue US " and include "color doppler" or vasc. component if you used it. - desiree lerro, d.o. (radiologist)

Permalink Reply by robert g schwartz on December 28, 2009 at 10:07pm

its a shame that despite a wide body of literature that aium would say that about paraspinal ultrasound...as if multifidus muscle atrophy there is any different then muscle atrophy somewhere else. see: http://piedmontpmr.com/dx_msk_psp_us_full.pdf for a blinded mxk us article vs mri

fyi, bcbs of illinois has also dropped coverage of limb msk us

Permalink Reply by Paula Woletz on December 29, 2009 at 9:38am

Could you direct us to a copy of the policy? When Illinois BCBS cited AIUM's position on non-operative spinal ultrasound in adults as a rationale to deny coverage for ALL musculoskeletal ultrasound, AIUM President Harvey Nisenbaum wrote a letter to the IL BCBS Chief Medical Officer stating that, "The AIUM agrees that non-operative spinal ultrasound in adults should be considered investigational. However, the clinical utility of diagnostic musculoskeletal ultrasound and ultrasound-guided interventional procedures has been well-documented for a variety of other indications. . . .We urge you to cover medically appropriate musculoskeletal ultrasound examinations performed according to accepted guidelines and interpreted by qualified individuals and practices."
Thanks!
Paula Woletz

Permalink Reply by robert g schwartz on December 29, 2009 at 9:28pm

i know this because we have called to verify benefits on a patient who visits us from illinois. We were told quite clearly all dx us of limb studies are denied (b/c illinios). my office web site is piedmontpmr.com. you can call us from there and ask to speak to insurance. they will pull the case for you. I was so flabergasted that i actually spoke to the supervisor myself....after a long discussion with her and insisting that i speak to the medical director i was told "oh, if you send a predetermination request for otherwise denied coverages our panel will consider it"....(this was not a typical preauthorization for covered services request)...AIUM has to be loud and clear or it will become a contagion.

Paula Woletz said:

Could you direct us to a copy of the policy? When Illinois BCBS cited AIUM's position on non-operative spinal ultrasound in adults as a rationale to deny coverage for ALL musculoskeletal ultrasound, AIUM President Harvey Nisenbaum wrote a letter to the IL BCBS Chief Medical Officer stating that, "The AIUM agrees that non-operative spinal ultrasound in adults should be considered investigational. However, the clinical utility of diagnostic musculoskeletal ultrasound and ultrasound-guided interventional procedures has been well-documented for a variety of other indications. . . .We urge you to cover medically appropriate musculoskeletal ultrasound examinations performed according to accepted guidelines and interpreted by qualified individuals and practices."
Thanks!
Paula Woletz

Permalink Reply by Robert Vranes, DPM on January 8, 2010 at 7:09pm

BCBSTX is part of a consortium including Illinois, New Mexico and Oklahoma. In November 2009, BCBS reclassified Nonoperative Spinal/Paraspinal Ultrasound in Adults AND MSK diagnostic ultrasound of the extremities as "experimental, investigational and unproven". You may read the entire policy review at:

http://medicalpolicy.hcsc.net/medicalpolicy/printPolicy.do?corpEntC......

The thrust of the article dealt with spinal and paraspinal issues. MSK ultrasound in the extremities got dragged in as a tail at the end of their report. As chairman of our state association's insurance committee, I have been working to resolve this issue but I have not made much progress to date. It is early in the game. I have been informed that some Illinois DPMs are receiving payment upon appeal with review of medical records. I understand that AIUM has written a letter of support to BCBSTX regarding the application of MSK diagnostc ultrasound in the extremities. Texas DPMs have been advised to continue to perform diagnostic ultrasound when clinically indicated and with appropriate documentation in the medical record. If the claim is denied, they are urged to appeal. If the appeal fails, they are urged to request peer review. We have not been far enough down the time line to see if this protocol will be effective in Texas. Please note that ultrasonic guidance for needle placement has not been affected by this policy change.

Professional societies representing rheumatology and physical medicine have been active in attempting to reverse this ill-conceived BCBS policy change.

In a possibly related development, BCBS New Jersey, on November 30, 2009, informed podiatrists that diagnostic ultrasound would be covered only if provided by a certified radiologist. The New Jersey state podiatry association has filed suit against BCBSNJ.

I think it would beneficial if AIUM could offer certification in MSK ultrasound of the extremities. This is a similar situation that occurred about 15 years ago when OB/GYN began to use ultrasound. The radiologists were not too happy. Standards and protocols were established and the issue was eventually resolved.

I hope this update has been helpful.

Robert Vranes, DPM
San Antonio, TX

Permalink Reply by Paula Woletz on January 19, 2010 at 10:20am

AIUM president Harvey Nisembaum just sent a letter to the head of medical affairs for the imaging management company that authored the MSK policy for Blue Cross Blue Schield of Texas, Illinois, and other states. In that letter, he wrote that while non-operative spinal ultrasound in adults is still considered investigational, the clinical utility of other MSK ultrasound exams and ultrasound-guided procedures is well documented. He sent a copy of the AIUM practice guidelines for the performance of MSK exams and the AIUM training guidelines in MSK ultrasound, and urged him to reconsider the policy and to cover medically appropriate MSK ultrasound exams.

I hope those of you in affected states will let us know if (hopefully, when) the policy is changed for the better.
Paulais

Permalink Reply by Robert Vranes, DPM on January 19, 2010 at 10:29am

I suggest that AIUM president Harvey Nisembaum send a copy of his letter to Allan Chernov, MD, Medical Director of BCBSTX, and who also oversees the medical directors for Illinois, Oklahoma and New Mexico. Dr. Chernov may be contacted at:

allan_chernov@bcbstx.com

901 South Central Expressway, North Building
Mail Drop E
Richardson, Texas 75080

Robert Vranes, DPM
San Antonio, TX

Permalink Reply by Paula Woletz on January 20, 2010 at 9:14am

Thanks for the information. I've attached a copy of the letter that just went out.
Paula

Attachments:

• BCBS TX letter re MSK US.pdf, 170 KB

Permalink Reply by Robert Vranes, DPM on January 20, 2010 at 2:51pm

Ms. Woletz,

Below is a copy of the letter that I sent to Dr. Chernov @ BCBSTX in November 2009. I have yet to receive a response. This letter was written from a podiatric perspective. It offers a spirited discussion and refutation of BCBS's scientific foundation on which it based its decision.

The only restricted CPT code that is pertinent to our profession is 76880. Our group of 19 podiatric physicians include 8 doctors who use diagnostic ultrasound. In the four month period of September - December 2009, we had 62 claims rejected by BCBSTX. Robert Vranes, DPM



The Podiatry Group of South Texas, PA
Robert R. Vranes, DPM
9150 Huebner Road, Suite 270
San Antonio, Texas 78240
210.561.7080
210.561.7040 Facsimile

November 16, 2009

BlueCross BlueShield of Texas
Allan Chernov, MD, Medical Director
901 South Central Expressway, North Building
Mail Drop E
Richardson, Texas 75080

VIA: E-mail to allan_chernov@bcbstx.com

RE: BCBS Diagnostic Ultrasound Medical Policy Update

Dear Dr. Chernov:

I am writing to you, in my capacity as Chairman of the Insurance Committee of the Texas Podiatric Medical Association (TPMA), regarding the “Non-Operative Spinal and Musculoskeletal Ultrasound, RAD602.016, effective 09-01-2009” revised medical policy that was published on the BlueCross BlueShield of Texas (BCBSTX) website on 10-15-2009. Since early November, I have received numerous complaints and expressions of concern from TPMA members regarding implementation of this policy with respect to patient care issues. This has caused a degree of confusion among our podiatric sonographers who have provided these radiology services, some for many years, without incident, and as a benefit to our patients.

Your newly adopted Medical Policy has concluded that “non-operative musculoskeletal ultrasound is considered experimental, investigational and unproven for other musculoskeletal indications …” This is followed by a list of musculoskeletal (MSK) conditions including many that fall within the scope of podiatric medicine including: tendon injuries, bursae and synovial sheath pathology, ligament injury, inflammation, and foreign bodies. Specifically, the policy states that CPT code 76880 (US examination) is included (ie, will not be a covered service).

Page 2 of the policy describes, under “Description:” all of the virtues of diagnostic MSK US, including its application in: tendon tears including the Achilles tendon, abnormalities of muscles, fluid collections within these structures, soft tissue tumors, early changes of rheumatoid arthritis. It then details its use in spinal dysraphism in newborns and older children.

Page 3, under “Rationale”, the appropriateness of MSK ultrasound in spinal disorders, newborn vs adult is discussed and concludes that “Nonoperative spinal/paraspinal ultrasound in adults should be consider investigational.” The first twenty-seven citations under “References:” includes articles dealing with this topic.

Page 4, par. 5, begins a discussion of MSK US acknowledging that it has replaced other imaging techniques as the method of choice, made possible new areas of diagnostic investigation, and that the equipment is cheaper and more readily available than ionizing radiation. It acknowledges that imaging of superficial soft tissue structures is not yet widely practiced by the general medical community but offers no reason for it.

Page 4, par. 6, is where things begin to get interesting. Three articles were referenced, of the four cited in your bibliography, in apparent support of your newly adopted Medical Policy (by Mouterde, Taggart, and Joshua).

I was unable to retrieve the original article by Mouterde but, relying on your summary, he is referring his comments and conclusions specifically to the intra-operative use of contrast enhanced ultrasound. This form of US is used in evaluation of the internal organs, including their potential cancers, and not to musculoskeletal ultrasound. It is not pertinent to your policy revision.

I was successful in retrieving the original articles by Taggart, Joshua, and Brushoj. I have given these articles careful review in their totality. The Taggart article dealt with issues involving the training of rheumatologists in MSK US in the United Kingdom. He cites that it is “now used regularly as a clinical tool to assist with patient assessment and joint or soft tissue injection.” Also, “In a recent audit, we estimated that US scanning influenced the clinical management of our patients in 70% of cases.” Due to their education and training in cadaveric and surgical anatomy, podiatrists are well positioned to experience a very shallow learning curve in the application of MSK US and are appropriately trained in the use of MSK US. It is not pertinent to denying services related to MSK US.

Joshua, from Australia, provided a literature review relying heavily (64% of papers) on the experience of rheumatologists in their treatment of inflamed joints of the hands. He makes a seemingly damning conclusion by stating: “The study concluded that although the majority of research reports of power Doppler ultrasound assessment of the musculoskeletal system evaluated validity (my emphasis), less that half reported reliability and responsiveness.” What does this mean? Validity was the most studied performance characteristic (94% of papers). This is the ability of US to work as a surrogate and is measured against other accepted methods of assessing the disease. Reliability relates to the reproducibility of the examination from observer to observer. This is very difficult to carry out since US exams are performed in real time and over the entire anatomical structure being examined. Responsiveness is the ability to record a
change in intervention. Again, this could be affected by real time issues. This was what Joshua was referring to (diminished reliability and/ responsiveness) in criticizing the potential use of US in clinical trials. Joshua admits that this problem is being addressed (as of 2006) as reported in articles by Szkudlarek, Filippucci, Naredo, Strunk and their coworkers. In my own experience, it is very easy to measure changes in the thickness in the plantar fascia as a result of the response to steroid injection therapy. This is not much of an issue for podiatric sonographers. The conditions that we evaluate and treat in the foot and ankle are very limited in structure and are easily observed or measured. There were no references by Joshua from the orthopedic or podiatric literature.

Brushoj, from Denmark, compared gross enlargement measurements of various foot and ankle tendons between US and MRI. In this study to determine validity, he found a high correlation with the Achilles tendon and a lower correlation with the posterior tibial or anterior tendons. I am not sure of the purpose of his study. Gross enlargement via either modality, is usually not an issue in the pathology of these structures. Intratendinous changes are of greater concern. Please review the attached article by Grant et al in The Journal of Bone & Joint Surgery (2005) for a more meaningful discussion on evaluating tendon pathology that is consistent with contemporary orthopedic and podiatric practice. In many cases, such evaluations can be carried out just as accurately, at much greater cost efficiency, with US exam vs MRI exam.

Dr. Chernov, as in many areas of medical practice, there may be chasms or nuances of opinion or experience regarding the diagnosis or management of a given condition or disease process. However, the use of diagnostic ultrasound for MSK disorders (non-spinal) has been an accepted medical practice in the United States for decades. I have referred patients to radiologists for US exam of the foot and ankle for almost twenty years.

MSK US, in the United States, is cost efficient and beneficial in the evaluation of superficial foreign bodies, subcutaneous cysts and masses, refractory metatarsalgia, tendon and ligament integrity. The revised Medical Policy change will dramatically affect the level of care rendered to patients by radiologists and podiatric physicians. It offered no advice to the clinician on what alternative special imaging modalities to use to better evaluate these conditions.

The Current Procedure Terminology (CPT) codes describing this level of work have been included in the CPT Manual for many years without a T- code attachment that would classify them experimental. It is now as if BCBS has “discovered” something that no one else in the medical profession is aware of. It removes the benefits of these services by administrative fiat by “reclassifying” the codes. This may represent a conflict with the copyright owners of the CPT Manual.

The reference articles used as a basis to form the revised Medical Policy were not drawn from any peer review orthopedic or podiatric sources. The formation of the revised policy, therefore, lacks balance and the perception that all professional bodies of experience were not properly weighed and considered. For that reason, I am providing to you a bibliography drawn from those sources.

The revised Medical Policy disrupts currently accepted medical practice. It places physicians in a position to refer for more expensive special imaging studies that the patient may not need and may be subjected to higher deductibles and co-insurance requirements, in addition to time off work needed to complete these examinations. If there are concerns about potential utilization or misapplication issues of MSK, let us mutually investigate and evaluate those concerns in the interests of enhancing patient care in the most cost efficient manner possible.

Please give my concerns, expressed on behalf of the TPMA membership, your careful review. I anticipate a favorable response. In the interim, I request that BCBSTX suspend the revised Medical Policy, with respect to non-operative US in the extremities, pending further review. I do note that while currently denying payment for 76800, BCBSTX continues to request medical records from the providers of that service. If you desire a meeting to discuss this further, I am available to meet with you. In that event, I would like to be accompanied by a member of the Executive Board of the Texas Podiatric Medical Association and a recognized, podiatric expert in the use of diagnostic ultrasound.

Thank you very much.


Sincerely,




Robert R. Vranes, DPM
Chairman, Insurance Committee
Texas Podiatric Medical Association



References: Taggart, A., Filippucci, E., et al. Musculoskeletal ultrasound training in rheumatolofy: the Belfast experience. Rheumatology (Oxford) (2006 January) 45(1):102-5.

Joshua, F., Edmonds, J., et al. Power Doppler ultrasound in musculoskeletal disease: a systematic review. Seminars in Arthritis and Rheumatism (2006 October) 36(2): 99-108.

Brushoj, C., Henriksen, B.M., et al. Reproducibility of ultrasound and magnetic resonance imaging measurements of tendon size. Acta Radiologica (2006 November) 47(9): 954-9.

Attachments: Grant, T.H., Kelikian, A.S., et al. Ultrasound Diagnosis of Peroneal Tendon Tears. A Surgical Correlation. The Journal of Bone & Joint Surgery (2005) 87:1788-94.

Ultrasound References (1-21)

Permalink Reply by Robert Vranes, DPM on February 1, 2010 at 10:19am

BCBS Diagnostic Ultrasound Policy Reversal

I have been informed of the following policy change by Dr. Allan Chernov, Medical Director of BlueCrossBlueShield of Texas:

"The Medical Policy Medical Directors (MPMDs) of Health Care Service Corporation (HCSC) have decided to put the current Medical Policy coverage position for Diagnostic Ultrasound on hold while continuing their ongoing review of this area. This means that effective 2/1/10, CPT 76880 will not be denied in our claim system.

Because this action is based on a change in a medical policy coverage position, it will not be applied retroactively to claims submitted with CPT 76880."

This change will effect BCBS policy holders in Texas, New Mexico, Oklahoma and Illinois

Robert Vranes, DPM
Chairman, Insurance Committee
Texas Podiatric Medical Association