Ultrasound-Guided Procedures by Anesthesia Providers

Summary

This article is intended to inform readers of the increased utilization of ultrasound services within the specialty of anesthesia and to forecast future payer policy concerning its reimbursement.

Recently, the American Medical Association (AMA) revised its regulations to allow for the billing of ultrasound guidance (USG) with arterial lines. Historically, such a service was limited to central venous pressure or central line placement (bundled with Swan-Ganz catheters), as well as acute pain blocks. The "unbundling" of this service for arterial line means additional revenue for many anesthesia groups that utilize this clinical practice, at least for now.

In reviewing our clients' historical billing data, we determined that only 12.6 percent of arterial lines placed included documentation of USG being used. This means that most anesthesia practices are either performing these procedures without USG, or that they are using ultrasound and not currently documenting it within their procedural notes or anesthesia records.

It should be noted that even though the AMA now allows for the arterial line/USG combination to be billed separately, not all insurance plans will pay for both services (59.9 percent dual payment rate). However, for those that do, ultrasound reimbursement averages $18.65.

The use of ultrasound as a modality for both lines and blocks has dramatically increased over the past ten years, due to the service becoming the standard of care for most anesthesia practices (see table below). Interestingly, this has been driven by the anesthesia groups themselves, and not by hospital bylaws. Most new anesthesiologists coming out of residency programs have been thoroughly trained in the use of ultrasound techniques, while some of the more seasoned physicians who were trained using anatomical markers have undergone additional certification to refine their skillset.

Why has USG become the standard of care? Has it improved the consistency and quality of nerve blocks and made it possible for more providers to perform such blocks? The answer appears to be a resounding "yes." According to an abstract published by the U.S. National Library of Medicine/National Institutes of Health, USG shortens the block performance time, reduces the number of needle passes and shortens the block onset time. Becker's Hospital Review also published a recent study on the benefits of ultrasound-guided peripheral nerve blocks in total knee arthroplasty procedures and concluded that its use enhanced the speed, safety and success of the regional analgesic technique.

It is also worth mentioning that documentation guidelines for the billing of ultrasound services has changed multiple times over the past few years. This typically means a higher level of scrutiny for payment and the potential for post-payment reviews. It also signifies that insurance plans recognize the increased utilization and cost associated with these procedures. Some of our clients have seen an increase in record requests from payers to determine if the ultrasound image was archived in a retrievable format, and whether there was a satisfactory interpretive statement included in the procedural note beyond "localization." This is especially true for ultrasound used conjunction with invasive monitoring lines.

In conclusion, the future of payment for USG by anesthesia providers is uncertain. When fluoroscopy first became the standard of care for chronic pain injections, it was initially carved out and paid as a separate service by insurance plans. At that time, not all physicians performing pain procedures were fellowship trained and using radiological guidance for procedures such as facet and sacroiliac joint injections. As utilization increased, the AMA revised the descriptors for these procedures in the CPT book to include fluoroscopy, thus making its use a requirement and bundling payment into the procedure itself. It is safe to assume that payers will take the same approach with ultrasound. Hopefully, it will take several years for that policy change to come to fruition. If you have any questions on the nuances of ultrasound billing, please contact your client manager.