The Future of Payment for Ultrasonic Guidance: Predictions for Anesthesia Providers
SUMMARY
During the past five years, the code for fluoroscopy guidance in the management of chronic pain (77003) has been bundled into all of the most common chronic pain modalities, such as paravertebral facet joint injections and transforaminal injections. The same thing seems to be happening with the use of ultrasonic guidance (USG) in the placement of nerve blocks and catheters for postoperative pain management. What was previously one code for a single shot spinal injection in the lumbar space (62311) is now two codes (62322 and 62323)—one indicating that USG was used and one indicating that it was not used. The net effect of this change is a dramatic reduction in payment for guidance. It is likely that USG will ultimately be bundled into most of the commonly performed nerve blocks used in acute pain management, and its monetary value will diminish.
The use of ultrasonic guidance (USG) in the placement of nerve blocks and catheters for postoperative pain management has become a standard of care for most anesthesia practices. It is also widely used for confirmation of vascular access, especially for the placement of central venous pressure lines (CVPs).
Many would argue that USG has allowed anesthesia providers to perform these services more consistently and with better results. The clinical reality is that, over the past five years, the use of USG has increased dramatically, although its use appears to be leveling. While USG may have enhanced the value of services these practices provide, the economics of medicine have imposed a different reality. Once a procedure or clinical modality becomes a standard of care, its economic value falls precipitously.
A 2013 article in The Scientific World Journal by Abdullah S. Terkawi, MD, summarizes the prevailing view of USG. "Ultrasound is a safe, portable, relatively inexpensive and easily accessible imaging modality, making it a useful diagnostic and monitoring tool in medicine," Dr. Terkawi writes. "Ultrasound-guided peripheral nerve block blockade is perhaps the most popular ultrasound application . . . the gold standard for regional anesthesia."
There are really only two requirements: ultrasound machines and anesthesia providers who know how to use the technology. Over the past five years, most hospitals have acquired the machines, and the majority of providers have mastered its use for a variety of applications associated with invasive monitoring and acute pain management.
The ABC client base reflects national trends. The chart below shows how utilization of the two most common applications, USG for needle placement (76942) and USG for vascular access (76937) have increased over time. This chart is based on a sample of ABC clients that have been using USG for five years.
A number of factors impact actual payment for a service.
- Is the service separately payable or bundled into another service?
- What are individual payer policies pertaining to the service?
- What is the overall payer mix of patients receiving this service?
Thus far, USG has been a separately payable service. In other words, if an anesthesiologist performs an interscalene block with USG, they are paid for the block (for code 64415) and for the USG (for 76942). This reimbursement pattern reveals a first potential point of vulnerability. A quick review of the use of fluoroscopy in chronic pain, a similar type of guidance technology, reveals that over the past five years, code 77003 has been bundled into all of the most common chronic pain modalities, such as paravertebral facet joint injections and transforaminal injections.
It appears likely that USG will follow suit. In fact, we already see evidence of this pattern with the new spinal injection codes. What was previously one code for a single shot spinal injection in the lumbar space (62311) is now two codes (62322 and 62323)—one indicating that USG was used and one indicating that it was not used. The net effect of this change is a dramatic reduction in payment for guidance.
The table below summarizes our experience comparing the old and new codes for lumbar injections based on a sample of 90 clients across the country.
A review of specific payer policies does not reveal any obvious red flags; however, CPT guidelines have been tightened recently. According to the new guidelines, it is no longer enough to know the image has been retained for possible audit; the provider must explain in their own words why USG was used. However, for the most part, claims are being paid and rates for the two codes listed above have remained constant.
Overall average payment per service performed has started to decline. This is a function of payer mix. As the technology is applied to a larger sample of patients, inevitably, the percentage of Medicare and Medicaid patients, those with the lowest payment rates, increases.
What does all of this tell us about the ongoing revenue potential of USG? We are not optimistic. There is every indication that, as happened in chronic pain, USG will ultimately be bundled into most of the commonly performed nerve blocks used in acute pain management, and its monetary value will diminish. The only question we cannot answer is how soon this will happen.
With best wishes,
Tony Mira
President and CEO