Hospital Medicine Point of Care Ultrasound Credentialing: An Example Protocol
Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.
© 2017 Society of Hospital Medicine
BILLING
Coding, billing, and reimbursement for focused ultrasound has been supported through the AMA Physicians’ Current Procedural Terminology (CPT) 2011 codes, which includes CPT code modifiers for POCUS.84 There are significant costs associated with building a HM ultrasound program, including the education of hospitalists, ultrasound equipment purchase and maintenance, as well as image archiving and QA. The development of a HM ultrasound billing program can help justify and fund these costs.19,85
To appropriately bill for POCUS, permanently retrievable images and an interpretation document need to be available for review. HM coders are instructed to only bill if both components are available. Because most insurers will not pay for 2 of the same type of study performed within a 24-hour period, coders do not bill for ultrasounds when a comprehensive ultrasound of the same body region is performed within a 24-hour period. The workflow that we have developed, including ordering, performing, and documenting, allows for easy coding and billing.
BARRIERS AND LIMITATIONS
While POCUS has a well-established literature base in other specialties like emergency medicine, it has been a relatively recent addition to the HM specialty. As such, there exists a paucity of evidence-based medicine to support its use of POCUS in HM. While it is tempting to extrapolate from the literature of other specialties, this may not be a valid approach.
Training curves in which novice users of ultrasound become competent in specific applications are incompletely understood. Little research describes the rate of progression of learners in ultrasound towards competency. We have recently started the QA process and hope that the data will further guide feedback to the process.
Additionally, with the portfolios, the raters’ expertise may not be stable (develops through experience). We aim to mitigate this by having a group of raters reviewing each file, particularly if there is a question about if a submission is of high image quality. A notable barrier that groups face is support from their leadership regarding POCUS. Our group has had support from the chief medical officer who helped mandate the development of POCUS standards.
LESSONS LEARNED
We have developed a robust collaborative HM POCUS program. We have noted challenges in motivating all providers to work through this protocol. Development of a POCUS program takes dedicated time, and without a champion, it is at risk for failing. HM departments would be advised to seek out willing collaborators at their institutions. We have seen that it is useful to partner with some experienced emergency medicine providers. Additionally, portfolio development and feedback has been key to demonstrating growth in image acquisition. Deliberate longitudinal practice with feedback and successive refinements with POCUS obtain the highest yield towards competency. We hope our QA data will provide further feedback into the credentialing policy and procedure.
SUMMARY
It is important that POCUS users work together to recognize its potential and limitations, teach current and future care providers’ best practices, and create an infrastructure that maximizes quality of care while minimizing patient risk.
We are hopeful that this document will prove beneficial to other HM departments in the development of successful POCUS programs. We feel that it is important to make available to other HM departments a concise protocol that has successfully passed through the credentialing process at a large tertiary care medical system.
Acknowledgments
The authors would like to acknowledge Susan Truman, MD, for her contributions to the success of the POCUS committee at Regions Hospital. The authors would like to acknowledge Kreegan Reierson, MD, Ankit Mehta, MBBS, and Khuong Vuong, MD for their contributions to the success of POCUS within hospital medicine at HealthPartners. The authors would like to acknowledge Sandi Wewerka, MPH, for her review and input of this manuscript.
Disclosure
The authors do not have any relevant financial disclosures to report.
