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20 Credentialing andPrivileging
335
Key Points
• No one department/specialty owns any privilege.
• AMA policy on ultrasound afrms that ultrasound imaging is within the scope of
practice of appropriately trained physicians. Training criteria should be based on
specialty-specic guidelines
• Follow the current ACEP ultrasound guidelines during the credentialing and
privileging process
• ACEP supports that emergency physicians obtain privileges consistent with their
documented training, experience, and current clinical competence. The recom-
mendations for clinical privileging should come from the director of the emer-
gency department.
• The credentialing and privileging process must be fair and unbiased.
• The best way to guarantee never losing a privileging conict is to never have one
in the rst place.
References
1. American College of Emergency Physicians. Physician credentialing and delineation of clini-
cal privileges in emergency medicine. Ann Emerg Med. 2006;48:511.
2. Epstein RM, Hundert EM. Dening and assessing professional competence. JAMA.
2002;287(2):226–35.
3. III.Sup. Ct., 33 III.2d 326, 211 N.E.2d 253 (1965).
4. Hirsch EA.Establishing a fair privileging process in your hospital. Fam Pract Manag. 1996;3(4):22–40.
5. Burton JH, Miner JR, Shipley ER, etal. Propofol for emergency department procedural seda-
tion and analgesia: a tale of three centers. Acad Emerg Med. 2006;13:24–30.
6. Green SM, Roback MG, Krauss B, etal. Predictors of airway and respiratory adverse events
with ketamine sedation in the emergency department: an individual-patient data meta-analysis
of 8,282 children. Ann Emerg Med. 2009;54:158–68.
7. Pena BMG, Krauss B.Adverse events of procedural sedation and analgesia in a pediatric emer-
gency department. Ann Emerg Med. 1999;34:483–90.
8. American Medical Association. House of Delegates. Privileging for ultrasound imaging.
2001:H-230.960.
9. American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg
Med. 2009;53:550–70.
Chapter 21
Accreditation inPoint of Care Ultrasound
Michael P.Mallin
Objectives
– Describe and Dene Accreditation in Medicine
– Why Accreditation for Clinical Ultrasound
– The Accreditation process
Introduction
The concept and process of accreditation has seen signicant growth in medicine in
recent years. Each year it seems additional sites, procedures, and applications of
healthcare are seeking accreditation from governing bodies, private companies, and
nonprot organizations.
The concept of accreditation in healthcare began in 1951 with the formation of
the Joint Commission on Accreditation of Hospitals (JACH, later known as JACHO)
[1]. In 1965 Medicare tied conditions of participation (reimbursement) to JCAH
accreditation and changed healthcare forever.
Since 1951 accreditation by external entities has become the accepted norm for
validation and scrutiny of the credibility of a healthcare system, process, or group.
Hospitals now often seek accreditation to become a Stroke Center, a STEMI receiving
center, or a Trauma Center. Many hospital radiology based ultrasound departments,
Vascular ultrasound Labs, Echocardiography labs, and Maternal and fetal medicine
M.P. Mallin, MD, FACEP
Division of Emergency Medicine, Department of Surgery, University of Utah School of
Medicine, Salt Lake City, UT, USA
e-mail: michaelmallin@gmail.com
V. S. Tayal et al. (eds.), Ultrasound Program Management,
https://doi.org/10.1007/978-3-319-63143-1_21
337© Springer International Publishing AG 2018
338
M.P. Mallin
ultrasound departments are already receiving accreditation from groups such as the
American College of Radiology [2], The American Institute of Ultrasound in Medicine
[3], and the Intersocietal Accreditation Commission [4]. Yet no external entity had
created an appropriate accreditation process for clinical based, point-of-care
ultrasound.
In 2007 the American College of Emergency Physicians passed Council
Resolution 32:
RESOLVED, That ACEP, in cooperation with all established College liaisons and
relationships with other medical specialty societies, the American Medical
Association, the Alliance for Specialty Medicine, the Coalition for Patient-
Centric Imaging, and other interested parties actively and fully opposes the impo-
sition upon the specialty of Emergency Medicine of any accreditation programs
developed, offered, and/or governed solely by other specialties; and be it further.
RESOLVED, That the Board of Directors of ACEP submit a comprehensive report
to the Council at the 2008 Council Meeting regarding the adoption and execution
of a strategic plan to address the long and short-term accreditation issues relating
to the performance and interpretation of imaging studies by emergency physi-
cians and, specically, emergency ultrasound [5].
From 2007 to 2015 the ACEP Accreditation Subcommittee of the Ultrasound
Section was tasked in developing what eventually became The Clinical Ultrasound
Accreditation Program or CUAP (http://cuap.acep.org). In 2015 CUAP rst started
accepting application and accrediting hospitals in the performance of clinical ultrasound. This program includes standards such as administration of ultrasound program, education and training of healthcare providers, performing and interpreting
ultrasound examinations, equipment management, transducer disinfection, image
acquisition and retention, and condentially and privacy.
What Is Accreditation?
Denition: Accreditation is a process of review that healthcare organizations
participate in to demonstrate the ability to meet predetermined criteria and
standards of accreditation established by a professional accrediting agency.
Accreditation represents agencies as credible and reputable organizations
dedicated to ongoing and continuous compliance with the highest standard of
quality.
Accreditation, credentialing, and privileging are often confused and used interchangeably within the healthcare setting. Yet each of these is quite different. As it
pertains to medicine and specically physician oversight:
21 Accreditation inPoint of Care Ultrasound
339
“What CUAP Does……” Accreditation is a self-assessment and external peer
assessment process used by a healthcare entity to accurately assess the facility’s
level of performance in relation to established standards and to implement ways to
continuously improve.
“What theUltrasound Director Does……” Credentialing is the process of gath-
ering information regarding a physicians qualications and capacity for appointment to the medical staff and those procedures implied by that appointment.
What theHospital Medical Board Does……. Privileging is the authority granted
to a physician by a hospital governing board to provide patient care in the hospital.
Clinical privileges are limited by the individual’s professional license, experience,
and competence.
Thus, when we are discussing the process of providing credibility to the process by
which an ultrasound division within a hospital entity is directed, we are talking
about accreditation. CUAP or any other form of accreditation does not credential or
privilege healthcare providers to perform ultrasound, but may approve the process
by which the ultrasound director may credential them.
Why Do WeNeed Accreditation?
There are many reasons why accreditation can benet your group, hospital, and
ultrasound program. These include standardization, quality assurance, and recognition. At its essence, though, accreditation is meant to give you direction and
organization in establishing and maintaining an exceptional ultrasound
program.
One of the greatest advantages of accreditation is organization. Most accreditation programs such as CUAP outline necessary requirements for a successful, wellrun, and standardized ultrasound program. Guidelines such as machine maintenance,
credentialing standards, and probe cleaning are often created by the accrediting
body and prevent “from-scratch” protocol creation for the ultrasound director. A
secondary advantage to this is that in meeting these requirements, directors can
often ask for hospital, departmental, or division support.
Take, for example, endocavitary probe cleaning. It can be difcult convincing
your chair or hospital administrators to enact a complicated and expensive probe
cleaning policy or purchasing the necessary equipment to run such a policy. If, however, that policy is necessary to gain accreditation, the ultrasound director can use
those requirements and accreditation itself as leverage to meet the minimum standards created by that accreditation.
Other reasons commonly mentioned to justify accreditation are [6]:
340
• Exhibit your commitment to clinical excellence.
• Display your commitment to the highest quality patient care.
• Provide credibility to peers and patients.
• Demonstrate that your practice meets the quality assurance requirements of a
growing number of insurance companies.
These are all reasonable reasons to seek accreditation. In the case of ACEP and
the Clinical Ultrasound Accreditation Program, it was also advantageous to create a
non-specialty specic accreditation process for point-of-care ultrasound or clinical
ultrasound so that emergency physicians and emergency departments did not have to
try to t into the mold of non-point of care, consultative ultrasound accreditation
programs.
M.P. Mallin
What Is theClinical Ultrasound Accreditation Program?
The Clinical Ultrasound Accreditation Program (CUAP) is an ACEP-governed
national accreditation organization with an understanding of clinical bedside ultrasound and a purpose of establishing a system of review for emergency departments
performing clinical, point-of-care ultrasound. This accreditation system promotes
the goals of quality, patient safety, communication, responsibility, and clarity
regarding the use of clinical ultrasound. As the use of ultrasound has become mainstream in clinical medicine, a need has emerged to promulgate and support national
standards for clinical ultrasound programs as detailed in the American College of
Emergency Physicians’ Ultrasound Guidelines [7].
CUAP has been developed with the express purpose of providing assistance to
those looking to implement a point-of-care ultrasound program, so that new programs can take advantage of expert experience to ensure they are meeting best practice standards.
This program includes standards in the areas of administration of ultrasound
programs, education and training of healthcare providers, performing and interpreting ultrasound examinations, equipment management, transducer disinfection,
image acquisition and retention, and condentiality and privacy.
What Are theRequirements ofCUAP Accreditation?
CUAP, being governed by ACEP, has set the minimum standard for accreditation in
an effort to match the ACEP Ultrasound Guidelines [7]. The ACEP 2016 Ultrasound
Guidelines are used in multiple specialties as the standard for point-of-care ultrasound. Further validity to these guidelines was gained in 2011 when American institute of Ultrasound In Medicine ofcially recognized them [8].
CUAP includes standards for administration of an ultrasound program, education and training of healthcare providers, performing and interpreting ultrasound
21 Accreditation inPoint of Care Ultrasound
341
examinations, equipment management, transducer disinfection, image acquisition
and retention, and condentiality and privacy.
Each Institution Will Be Expected to Meet the Following Criteria [9]:
• Every licensed healthcare provider using point-of-care ultrasound either meets
ACEP credentialing guidelines or is in the process of meeting these
guidelines.
• An emergency ultrasound coordinator/director must oversee the maintenance,
education, and monitoring of the ultrasound program.
• The program must also meet minimum standards of continuous quality manage-
ment (CQM).
• Each healthcare provider must complete a minimum amount of continuing medi-
cal education (CME) in each ultrasound credentialing cycle.
• All ultrasound equipment must meet state and federal guidelines and undergo
regular maintenance and cleaning.
• A policy must be in place for infection control following the local institution’s
standards.
• Periodic review of each healthcare provider must be performed.
• Reports must be generated for ultrasound exams and be included in the medical
record, and the images must be archived.
• Each institution should follow storage guidelines, respect patient condentiality
and HIPAA guidelines, and follow the ALARA Principle.
In summary, CUAP is designed to be clinician-relevant, bedside-focused, efcient, and complementary of current hospital processes and accreditation.
Other Ultrasound Imaging Accreditation Organizations
AIUM American Institute of Ultrasound in Medicine covering consultative and spe-
cic areas including Abdominal/General, Breast, Musculoskeletal (Diagnostic),
Musculoskeletal (Ultrasound-Guided Interventional Procedures), Dedicated
Thyroid/Parathyroid, Fetal Echocardiography, Gynecologic (with or without
3D), Head and Neck, Obstetric or Trimester-Specic Obstetric, OB with
Adjunct Detailed Fetal Anatomic US, Urologic, Ultrasound-Guided Regional
Anesthesia
ACR American College of Radiology - for radiology based consultative
ultrasound
IAC Intersocietal Accreditation Commission - for consultative vascular and cardi-
ology imaging
342
M.P. Mallin
Decision toSeek Accreditation
Accreditation may not be for everyone. Some groups are so small that they may not
benet from the standardization and quality assurances gained through the economies of scale associated with larger ultrasound divisions and accreditation. While
we encourage these groups to still strive for excellence in point-of-care ultrasound,
accreditation should by no means be set as an absolute requirement for emergency
departments practicing well within the standard of care, especially if those groups
are adhering to the ACEP Ultrasound Guidelines.
Established ultrasound divisions that are already meeting the accreditation minimum standards, are not receiving reimbursement denials for lack of accreditation,
and don’t need the guidance or leverage of applying for accreditation may also
choose to continue along their current path without seeking accreditation. However,
there is still recognition to be gained through accreditation.
Pitfalls
1. New US programs with basic elements of machine or director but without basic
elements of accreditation (e.g., scope of practice, clinical or infection control
protocols, credentialing, machine maintenance or QA) may not be ready for
accreditation processes.
2. Not reading or understanding the standards of the accrediting organization.
3. Choosing accreditation from an organization that is unfamiliar with the type of
your US practice.
4. Expecting accreditation to be a one time process. Accreditation is time limited
recognition that requires programs to maintain standards.
5. Expecting accreditation to resolve all program issues. Accreditation set a bar of
quality but other issues may occur.
Key Recommendation
1. Ultrasound accreditation should be a desired quality recognition for clinical
ultrasound programs.
2. Ultrasound accreditation can offer you guidance in developing a top-notch ultra-
sound program, all without having to start from scratch.
3. Develop your US program with awareness of the standards and expectation of
accreditation bodies.
4. Use accreditation to your program’s advantage including obtaining resources,
recognition, and personnel.
21 Accreditation inPoint of Care Ultrasound
343
References
1. Roberts JS, Coale JG, Redman RR.A history of the Joint Commission on Accreditation of
Hospitals. JAMA. 1987;258(7):936–40.
2. ACR Accreditation Modalities: Ultrasound. ACR Web 12 July 2015.
3. AIUM Ultrasound Practice Accreditation: What is AIUM accreditation. Accreditation.
AIUM.Web 12 July 2015.
4. Intersocietal Accreditation Commision: Echocardiography. IAC Web 12 July 2015.
5. Action on 2007 Resolutions. Actions on Council Resolutions. ACEP. 23 August 2010. Web 12
July 2015.
6. “AIUM Ultrasound Practice Accreditation: Why should my practice seek AIUM accreditation”
Accreditation. AIUM.Web 12 July 2015.
7. ACEP policy statement: ACEP Ultrasound Guidelines. ACEP Policy Statements. ACEP
October 2008. Web 12 July 2015.
8. Sound Waves Weekly. Sound Waves Weekly. AIUM, 17 Nov. 2001. Web. 12 July 2015.
9. About the Accreditation Process. Clinical Ultrasound Accreditation. ACEP, n.d. Web. 04 Jan.
2016.
Chapter 22
Point ofCare Ultrasound
ReimbursementandCoding
Jessica R. Goldstein and Stanley Wu
Objectives
1. Become familiar with coding lexicon
2. Understand how both clinicians and the facility get reimbursed for commonly
performed point of care ultrasounds
3. Understand requirements for compliant billing
Introduction
Clinicians use point of care ultrasound as a lean, patient-centered approach to guide
therapies, distill differential diagnoses, and conrm clinical impressions. Providers
perform focused ultrasounds based on their clinical examination of the patient and
communicate real-time results to the patient and family. Point of care ultrasound
delivers value to patients by expediting throughput, decreasing patient exposure to
radiation, improving safety of invasive procedures, and lowering costs [1–9].
Patients have more favorable opinions of physicians when point of care ultrasound
is performed [10].
Reimbursement for diagnostic and procedural ultrasound in the United States as
a separately identiable and billable procedure follows from the American Medical
J.R. Goldstein, MD, FACEP (*)
Department of Emergency Medicine, University Hospitals Ahuja Medical Center, Case
Western Reserve University, Cleveland, OH, USA
e-mail: jessica.goldstein4@uhhospitals.org
S. Wu, MD, MBA, FACEP
Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
V. S. Tayal et al. (eds.), Ultrasound Program Management,
https://doi.org/10.1007/978-3-319-63143-1_22
345© Springer International Publishing AG 2018
346
J.R. Goldstein and S. Wu
Association’s Current Procedural Terminology (CPT) annual publication [11].
Billing is essential to support the work required to deliver this service to emergency
patients and maintain a quality ultrasound program.
CPT Coding
Regardless of specialty and setting, all physicians use CPT codes to compliantly bill
for procedures. Appropriately trained clinicians credentialed and privileged by their
medical staff to perform a procedure described by CPT may bill for ultrasound.
The American Medical Association’s Specialty Society Relative Value Scale
Update Committee (RUC) assigns relative value units (RVUs) annually to each CPT
code. These updates are published through the CMS website as the Medicare
Physician Fee Schedule (MPFS) [12]. The RUC reviews both old and new CPT
codes and makes adjustments in RVUs according to the assumed resources required
to perform the work. Many private carriers reimburse services based on a multiple
of what CMS reimburses on the MPFS.
Global vs. Professional vs. Technical
Clinicians use ve-digit CPT codes to bill for a variety of diagnostic and procedural
ultrasounds. The MPFS lists three distinct ways to code for these CPT codes: (1)
global codes, (2) professional component (PC), and (3) technical component (TC).
The legal determination of the practice setting determines how the medical practice
bills for professional and facility (technical) services.
Ofce Setting
A traditional private practice ofce that is independent from the hospital is a “nonfacility” setting. Non-facility ofces typically bill global radiology codes. The
ofce pays for equipment, sonographer, physician interpretation, malpractice, and
any other overhead required. In return, the ofce receives a global payment to cover
these expenses (Table22.1).
Table 22.1 Professional and technical fees, site of service, and bundling
Ofce setting
(non-hospital) ED (hospital outpatient) Inpatient
Professional
fee
Technical
fee
Included in
global fee
Included in
global fee
Billed separately by physician Billed separately
Billed by hospital, may be subject to
bundling under OPPS or DRG if admitted
byphysician
Billed by hospital,
bundled into DRG