William B Schroedter, BS, RVT, RPhS, FSVU Time How Much Should I Have to Perform a Venous Insufficiency Exam? (SVU Performance Guidelines / CMS Data) William B Schroedter, BS, RVT, RPhS, FSVU

Disclosures Co-Owner Quality Vascular Imaging, Inc Virtual Vein Center

Why do we care! My Bias – an ultrasound exam takes however long it takes! Sonographer – “Back to back to back venous insufficiency exams with people in the waiting room from morning till night…... I feel like I am providing poor patient care and my back and shoulders are killing me” Physician – “I need that information to make clinical decisions” Physician owner / employer – “I cannot make any money if you take 90-120 minutes on every exam. If you can’t finish in less than 60” I will find someone who can!” Caveats – No meaningful enforcement mandating sonographer qualifications No quality mandate for reporting standards / documentation

Work-related musculoskeletal disorders in sonographers: a review of causes and types of injury and best practices for reducing injury risk -Carolyn Coffin Abstract: Work-related musculoskeletal disorders in sonography professionals have a reported incidence of 90%. These disorders are defined as conditions that are either caused by or aggravated by tasks performed in the workplace. These injuries have a financial and emotional impact on the worker and affect workplace productivity and quality patient care. The causes for these injuries are multifactorial and therefore require a variety of solutions for mitigating injury risk. Sonographer work postures, work schedules, task rotation, administrative support, and ergonomic workplace equipment all enter into the formula for reducing the incidence of these disorders. DOI https://dx.doi.org/10.2147/RMI.S34724

Who decides HOW MUCH I get paid?? Government Rule #3 Laws are made By the People For the People

Fact – It takes a LOT longer to study a patient with CVI than to rule out a DVT! Should we get paid more? Yes! Can we get paid more? Maybe! Would it be worth the effort? Probably not!

A Little History The American Medical Association (AMA) created, owns, and copyrighted the Current Procedural Terminology (CPT) code descriptions. The current codes (93970, 93971) for venous duplex ultrasound imaging have been in use since the 1980’s and these are well established. The AMA participates in a number of specialized of hybrid committees which are responsible for valuing the direct inputs for equipment, labor, and space, and making recommendations to the Center for Medicare/Medicaid Services (CMS) about reimbursement policy.  

The following AMA Committees each have a role in this process. CPT Editorial Panel – generates procedure descriptions based on input from the professional organizations for all procedures performed. Practice Expense Advisory Committee (PEAC) – This committee reviews survey data to determine reliability and compliance with rules for evaluating data. The data must meet fairly rigorous and well defined standards to even be considered. Relative Value Scale Update Committee (RUC) – reviews PEAC data and evaluates physician work data, technical work data, equipment and space, and makes recommendations for valuation of CPT codes. CPT Editorial Panel – generates procedure descriptions based on input from the professional organizations for all procedures performed. Recommendations for any changes to code descriptions are forwarded to the AMA for review and approval and then the AMA recommends changes to CMS. If a CPT code is accepted by the Editorial Panel, if then needs to be valued. Practice Expense Advisory Committee (PEAC) – This committee reviews survey data to determine reliability and compliance with rules for evaluating data. The data must meet fairly rigorous and well defined standards to even be considered. If deemed acceptable, the PEAC makes recommendations to CMS for valuing the CPT code. However, the actual reimbursement is not set by the PEAC. Relative Value Scale Update Committee (RUC) – reviews PEAC data and evaluates physician work data, technical work data, equipment and space, and makes recommendations for valuation of CPT codes. The SVU Advocacy committee, typically working with the Society of Vascular Surgery (SVS) has been extremely active in this process over the past 2 decades. Data are collected from members and are then used in these descriptions. Most CPT codes are on a five-year review cycle. So to re-iterate, it is not enough just to have the ACP or even multiple groups state that a venous insufficiency study takes 75” compared to a venous thrombosis study at 45”, this must be demonstrated by a well – defined survey process.

Physicians Fee Schedule Resource-Based Relative Value Scale (RBRVS) Initial based on the Harvard University study. RBRVS established as the standardized physician payment schedule in 1992 The factors to determine physician work include: Time Technical skill and physical effort Mental effort and judgment Stress due to the potential risk to the patient. Physician work relative values regularly updated CMS must review at least every five years.

RVS Updating Committee (RUC) Composed of representatives of major national medical specialty societies, ex-officio members Specialty Society performs survey for each code Data presented to the PEAC If deemed acceptable, the RUC makes the RVU recommendations to CMS CMS relies heavily upon RUC recommendations, accepting > 90% of RUC recommendations annually.

Sonographer time is only 1 piece of the equation. The SVU Advocacy committee, typically working with the Society of Vascular Surgery (SVS) has been extremely active in this process over the past 2 decades. Data are collected from members and are then used in these descriptions. Not enough just to have the ACP or even multiple groups state that a venous insufficiency study takes 75” compared to a venous thrombosis study at 45”, this must be demonstrated by a well – defined survey process. Sonographer time is only 1 piece of the equation. CPT Editorial Panel – generates procedure descriptions based on input from the professional organizations for all procedures performed. Recommendations for any changes to code descriptions are forwarded to the AMA for review and approval and then the AMA recommends changes to CMS. If a CPT code is accepted by the Editorial Panel, if then needs to be valued. Practice Expense Advisory Committee (PEAC) – This committee reviews survey data to determine reliability and compliance with rules for evaluating data. The data must meet fairly rigorous and well defined standards to even be considered. If deemed acceptable, the PEAC makes recommendations to CMS for valuing the CPT code. However, the actual reimbursement is not set by the PEAC. Relative Value Scale Update Committee (RUC) – reviews PEAC data and evaluates physician work data, technical work data, equipment and space, and makes recommendations for valuation of CPT codes. The SVU Advocacy committee, typically working with the Society of Vascular Surgery (SVS) has been extremely active in this process over the past 2 decades. Data are collected from members and are then used in these descriptions. Most CPT codes are on a five-year review cycle. So to re-iterate, it is not enough just to have the ACP or even multiple groups state that a venous insufficiency study takes 75” compared to a venous thrombosis study at 45”, this must be demonstrated by a well – defined survey process. These committees determine only the “relative value” for a given procedure but it is actually Congress who determines what this relative Value unit (“RVU”) is worth and what we eventually get paid.

Medicare Fee Schedule Formula RVU (Relative Value Unit) Total RVUs = Physician Work RVUs + Practice Expense RVUs + Malpractice RVUs + Geographic Modifier Payment = RVUs x Conversion Factor

RBRVS Data Evaluation of Dialysis Access 93990 59 Procedure CPT Code # of “ Evaluation of Dialysis Access 93990 59 Extracranial Cerebrovascular Duplex Ultrasound Evaluation 93880 67 Lower Extremity Arterial Duplex Evaluation  93925 94 93926 60 Lower Extremity Arterial Segmental Physiologic Evaluation 93922 39 93923 93924 73 Lower Extremity Venous Duplex Evaluation 93970 70 93971 45 Lower Extremity Venous Insufficiency Evaluation Mesenteric/Splanchnic Artery Duplex Imaging 93975 92 93976 53 Screening For Abdominal Aortic Aneurysms (AAA)  G0389   N/A Upper Extremity Arterial Duplex Evaluation 93930 76 93931 51

How much do I get paid?

RVU’s for 93970

www.ama-assn.org

Thank-you Time is non-refundable. Use it with intention! And thank you to the SVU for the investments it has made in this process. Time is non-refundable. Use it with intention!