AMSSM Letter to NCCI on Ultrasound Reimbursement

March 9, 2017

Niles R. Rosen, M.D.        Linda S. Dietz, RHIA, CCS, CCS-P
Medical Director              Coding Specialist

National Correct Coding Initiative
Correct Coding Solutions LLC
P.O. Box 907
Carmel, IN 46082-0907

Dear Dr. Rosen and Ms. Dietz,

On behalf of the American Medical Society for Sports Medicine, we are writing to you to register concerns about a recent NCCI change in the guidance for diagnostic and interventional ultrasound billing codes. Specifically, NCCI recently determined that both diagnostic and interventional codes should no longer be reported on the same date of service, and moreover, that patients should not be brought back on a separate date to recoup what were previously, and properly, billed as separate charges. While we agree no physician should improperly bill for two procedures done at the exact same time, we also believe that physicians should be fully paid for proper work performed. We believe this change, along with other recent cuts to ultrasound reimbursement rates will dramatically decrease the use of ultrasound as a diagnostic and interventional tool. The result of these changes and continued cuts will mean higher Medicare costs and lower patient satisfaction in the long run.

AMSSM is the largest organization in the United States solely made up of sports medicine physicians. Our members are physicians who graduate from accredited fellowships and have practices that are heavily focused on musculoskeletal medicine. Since our members are nonsurgical, they excel at moving patients toward recovery without the need for surgery. The sports medicine fellowship programs purposefully incorporate ultrasound training in the curriculum, because the procedure allows physicians to diagnose and often treat patients with the least inconvenience and often the least cost. Because an increasing number of our members utilize ultrasound in an outpatient setting, the need for referral for advanced, more expensive modalities such as MRI can be drastically reduced. Moreover, since imaging occurs at the point-of-care, with the patient in the room, patient satisfaction is high, decision-making can occur more quickly, and treatment can be instituted immediately in many cases.

Ultrasound has revolutionized outpatient musculoskeletal care, and holds great promise to bend the cost curve down for medical imaging, helping achieve the triple aim of improving patient experience, improving quality of care and reducing cost. Studies suggest that if ultrasound were substituted for MRI in appropriate instances, Medicare would save about half a billion dollars per year. Simply using ultrasound first in 30% of patients with rotator cuff (shoulder) pain would save Medicare about $31 million/year. That ultrasound is becoming a first line modality in many instances is reflected in the American College of Radiology’s Appropriateness Criteria for Diagnostic Imaging. Ultrasound guidance helps provide more effective clinical care. Accuracy of ultrasound-guided joint injections vary between 90-100%, vs. 64-81% for unguided injections. Accuracy of injections around tendon sheaths varies from 87-100% with ultrasound guidance vs. 27-60% without guidance. Thus, for reasons of cost, clinical appropriateness, and patient convenience, it is ultimately in the interest of Medicare to maximally utilize ultrasound imaging technology for their covered patients when appropriate.

It is therefore concerning to us that NCCI has chosen to implement a policy that continues to discourage physicians with adequate training in diagnostic ultrasound from providing the best possible care for their patients. By continuing to slash reimbursement rates, this forces physicians to reconsider investing in the necessary equipment and ongoing education and training to provide the service. We see no justification for this, as the procedures are completely separate and require separate blocks of time in the course of an office visit to accomplish.

The use of diagnostic and interventional ultrasound continues to be devalued, even as it is proven to be a better option for the patient, both in terms of cost and quality of care. AMSSM is very concerned that these code changes will have the unintended consequence of driving ultrasound from the marketplace, leading to an over-reliance on MRI and other more expensive imaging as the population ages. Indeed, these cuts jeopardize the access of Medicare patients to these technologies, and threaten a reduction in the participation rate of Sports Medicine physicians with Medicare. We believe that physicians should code ethically, based on their actual documented work product. We believe that doing that lays the groundwork for effective partnership with insurance companies to provide proper care for patients in an economically feasible way. To that end, we urge you to reconsider these coding guidelines and allow proper reimbursement for services rendered with musculoskeletal ultrasound.

We welcome further dialogue around this issue, and look forward to your response.

Sincerely,

Matt Gammons, MD
President