Nonradiologists power musculoskeletal ultrasound growth
Article Thumbnail ImageDecember 2, 2010 -- CHICAGO - Musculoskeletal ultrasound usage nearly quadrupled between 2000 and 2008, driven primarily by increased utilization by nonradiologists, according to a study presented Thursday at the 2010 RSNA meeting in Chicago.
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A team from Thomas Jefferson University in Philadelphia found that Medicare reimbursed 279.4% more musculoskeletal ultrasound studies in 2008 than they did in 2000. And nonradiologists, sparked by a surge in utilization by podiatrists, accounted for 71% of the more than 157,000 increase in utilization.

"Self-referral may be contributing to higher increases of nonradiologist musculoskeletal ultrasound utilization," said presenter Richard Sharpe, MD. "These studies, if that were the case, may then not represent an efficient allocation of healthcare dollars."

Musculoskeletal ultrasound is an emerging radiology subspecialty, and utilization has increased rapidly. In fact, utilization has risen so sharply that insurers in four states -- Illinois, New Mexico, Oklahoma, and Texas -- for a time denied all claims for nonoperative spinal and musculoskeletal ultrasound, declaring the studies to be "experimental." That policy was rescinded in February 2010, however.

To document trends in musculoskeletal ultrasound utilization in the Medicare population, the researchers obtained source data from the U.S. Centers for Medicare and Medicaid Services (CMS) Part B Physician/Supplier Procedure Summary Master Files from 2000 to 2008. The data cover all Medicare fee-for-service beneficiaries and omit HMO enrollees.

Records for allowed primary claims for extremity nonvascular ultrasound (CPT code 76880) were extracted, and providers were classified using Medicare's provider specialty codes.

To determine imaging volume, the researchers tabulated global claims and professional-component-only claims. Technical-component-only claims were excluded due to the possibility of double counting, Sharpe said.

The researchers found that 213,425 musculoskeletal ultrasound studies were primarily reimbursed by Medicare in 2008, up 279.4% from the 56,254 exams reimbursed in 2000. This also yields a 256.7% growth in utilization rate, which climbed from 171/100,000 Medicare beneficiaries in 2000 to 610/100,000 in 2008.

Of the 157,171 increase in studies over the time period, 111,268 (71%) were from nonradiologists.

Radiologists did contribute the plurality of overall claims in 2008, submitting 86,780 claims (40.7%). Podiatrists generated 66,585 (31.2%) claims and rheumatologists produced 22,270 (10.4%) claims.

Musculoskeletal ultrasound utilization by specialty
2000 2008 Change
Radiologists 40,877 86,780 + 45,903
Podiatrists 3,920 66,585 + 62,665
Rheumatologists 176 22,270 + 22,094
Primary care (nonrheumatology) physicians and internal medicine physicians and subspecialists 4,251 14,973 + 10,722
Physical medicine and rehabilitation physicians 519 5,058 + 4,539

"The podiatrists, which began the study as a lower user, are now using nearly as many studies as radiologists -- in just the past eight years," Sharpe said.

In other findings, the researchers noted that office (i.e., privately owned facilities) claims increased 635.8% in the study period, climbing from 19,372 in 2000 to 145,542 in 2008. Podiatrists submitted 66,103 (46.4%) of these claims, while rheumatologists contributed 22,220 (15.6%) and radiologists generated 19,390 (13.6%).

"The greatest increases in utilization occurred in private offices, and the nature of private offices is that some of these studies may be less scrutinized -- may be subject to less peer review, less validation, and less regulation," Sharpe said. "Consequently, these examinations may have wide ranges of quality."

The study team also discovered significant geographic variation by CMS region in the use of musculoskeletal ultrasound.

"In Kansas City, for example, about 20% of musculoskeletal studies are performed by nonradiologists," he said. "But in Atlanta, Dallas, New York, and San Francisco, that number is about 65%."

In addition, nearly all regions experienced significant increases in nonradiologist use of ultrasound.

"Only in Boston have nonradiologists used less [over the course of the study]," he said.

The researchers acknowledged a number of limitations of their research, including the lack of assessment of the quality or clinical appropriateness of individual ultrasound examinations. In addition, the study only evaluated the Medicare population, Sharpe said.

By Erik L. Ridley
AuntMinnie.com staff writer
December 2, 2010

Related Reading

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OIG eyes 'questionable' ultrasound claims, utilization, July 23, 2009

Ultrasound performs well in muscular trauma, July 13, 2009

Radiology faces declining share of musculoskeletal ultrasound, January 20, 2009

Study: Picking US over MRI for MSK imaging could save billions, March 6, 2008

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