I recently heard from a friend that medicare is going to stop reimbursing for vascular testing done in the office of podiatrists and family practitioners unless there is a certified vascular technician to do the tests. I also was told that the training provided by the PAD net folks does not count. I am at the end of my lease and I was about to buy out at the end of the lease. If this rumor is true I certainly won't be wanting to buy this equipment. Does anybody know anything about this?

Shari,

Unfortunately, what you are hearing is starting to occur already.  Sometimes, it even isn't going to be enough to even have a CVT performing the testing in your office.  The PADnet device does not meet certain Medicare LCD criteria for training and/or certification as a vascular laboratory.

Here is the language that currently exists in Florida under First Coast Service Options regarding the qualification requirements for performing Non-Invasive Physiologic Testing of Arteries:

 Obviously the purpose of the new LCD was not because of DPMs performing the testing in the office, but a retalitory move by Radiologists and cardiologists due to the amount and frequency of family practice, internal medicine and GPs performing the testing in their offices without appropriate radiology/cardiology supervision.

The other issue isn't the lower extremity ABIs.  The real problem is the amount of upper extremity arterial dopplers scanned for carotid bruits, etc., that have caused the LCDs to pop up.  I would imagine that the state PMAs would have to weigh in and have DPMs exempted, but I also understand that ALL imaging (ultrasounds, non-vascular) will be included as part of some certification lab process IS coming.

BCBS Illinois has already implemented a LCD regarding the use of non-vascular ultrasound examinations as exempted and non-covered as investigational due to the fact that they decided that the process of training and performance of the testing is not part of any official certification process.  Basically, they don't know WHO is trained to read an ultrasound, which specifically INCLUDES podiatric physicians.

Hopefully this gives you some information to make an informed decision to do the best for your practice.

Eric 

Thanks for the well researched and thought out reply.  The PAD net overall was a disappointment for my practice.  The reimbursements were less than anticipated and the time needed by the assistants to do it made it pretty unprofitable. I also worried about the overall accuracy of the test. The waveforms were helpful but the pressure measurements sometimes seemed really odd. I have paid quite a bit out in the lease and didn't want it to be for nothing, but in the long run it's probably for the best.

Sorry,

Does not surprise me.  Like everything else, a large part of this is money.

Two of our medicare HMO products now want a certified rad tech in the office for xrays.  Otherwise they have to be sent out to a freestanding facility.  Obviously a slight issue for post-op patients and patients with an injury.

Karr 

It would be illegal for MCR to discriminate against a podiatrist or any physician for performing any procedure if their state license permits them to perform such a procedure.

However, there are limits to that, for example, MCR may not reimburse an orthopedic surgeon for performing a cardiac angioplasty nor would they pay a cardiac surgeon for a hip replacement. That is referred to in the LCD where it states "Performed by a qualified physician, or (2) performed under the general supervision of a qualified physician by a technologist,etc.

No one would should argue against a podiatrist who is state licensed to perform non invasive testing, is not qualified to perform a PAD test (particularly if they can provide proof of training) and similarly no one would make the argument that an orthopedist is qualified to do a CABG.

I agree that the uptick in non invasive testing is not likely coming from DPM's (we are just too small a group of doc's -14,000 in the US) and I would like to review the BMAD data on 93922 and 93923 for DPM's and others if it is available. Once I do that, I can agree or disagree with the respondents (who probably are right) about the uptick in non invasive testing, but that likely has to do with all non invasive vascular testing(just as they said).

I don't use the PAD Net unit for the simple reason, that if I assume the same liability to perform the test as a vascular surgeon or anyone else licensed to perform the test, and I'm shelling out thousands for the unit, I might as well assume the liability for the other 40% (the interpretation) and do the whole test myself and be reimbursed for it.

I am not qualified to discuss the accuracy of the PAD unit as I have no experience with it.

As for MCR Advantage, Medicaid and other Non MCR plans, so long as there is no state discrimination law against exclusion, the non MCR carriers are free to limit whom they will reimburse. Note they are not saying you can't perform it, they just saying they will only reimburse specific practitioners.

In regard to the above threads, I have one point of contention. It was said in one of the earlier threads that Medicare will shortly require certification for non-vascular diagnostic ultrasound studies. Under NGSMedicare.com...under the "what's new section".... there is a recent policy update stating specifically that under Medicare payment guidelines (non-Medicare Advantage Plans) there is NO certification requirement for radiographs or ultrasound studies (non-vascular) performed in physician offices. However, Medicare will shortly implement a certification requirement for more advanced radiological studies (ie, MRI, CAT, etc).
In regard to physician based vascular testing, one may want to consider "renting" office space to a certified vascular physician/laboratory to provide in-house testing for your patients. However, such an agreement should be checked with your podiatry state counsel and society/association to insure it meets with current laws against any form of "fee-splitting." Such a rental agreement should not include a designated number of patients to be provided for study or designate a "fee" per patient study. The rent charged is dependent on overall staff salary, rent, utilities, insurance, etc. which should be properly documented. The rent is determined on the basis of renter's proportional use relative to the total hours per week. For eg. if the renter rents 5 hours per week of a 50 hour week (the charged rent should be 10% of office expenses for that week.)
I have been doing this in my practice for many reasons. The rental option I described above presents a  lower financial reimbursement  to one's practice vs. the practice billing for the arterial doppler study (technical component and interpretation.) However, after  years of receiving vascular reports that I say were "lacking,", I insist on toe pressures, PPG tracings, etc. and I get them right on the "spot." I feel this provides better care for my patients. Also, I can advise the vascular technician what specific regions of concern I have which I have found in the past to be omitted or "lost" by outside studies. I can better coordinate care for these patients. In addition, although I feel comfortable in reading an arterial vascular study and interpretation of waveforms, pressures, etc., an interpretation with report by a vascular physician should avert the legal pitfall of "failure to refer" especially when dealing with diabetic wounds.

I read my own vascular study (SPP and PVR test) and I am perfectly comfortable with my interpretation. In a nut shell, it's either good, marginal or BAD (ischemic)... and the BAD goes to a vascular specialist STAT. 

I don't think of the vascular test as a source of reimbursement, but an essential tool for my practice (mind you, it's a 100% wound care practice), clinically as well as for the medico-legal purpose. 

Just my 2 cents. KS. 

What may have been left out of my initial posting is that if you do perform any procedure, you are held to the same standards as any other specialist performing such a procedure, irrespective of your specialty.

Thus PCP's, Family Doc's, DPM's etc. will all be held to the same standards as a vascular surgeon when it comes to interpreting Non Invasive Vascular studies.

I don't see the other non-vascular MD's shunning from doing these tests nor should DPM's simply for the reason of "fear" of being held to a higher standard.

One should obtain the necessary training to perform such a test and recognize when a consult with another specialist (e.g. vascular surgeon, or interventional radiologist) is required. 

As to the advanced certification required by MCR, this will not involve ultrasound used by DPM's nor non invasive arterial testing, but only MRI, CT, MRA etc.

The largest specialties using ultrasound are not DPM's or vascular surgeons, but ob gyn, breast and and general surgeons, all of whom perform sonography in their offices. In addition to vascular surgeons, its doubtful any of these specialties would apply for advanced certification for their offices. For radiology, its quite another story.

One other note: I also perform digital PPG's and digital pressures as well as PVR's and Doppler wave form analysis along w/ doppler speed flow. All of which are important to interpret. ABI's are fairly useless, particularly in diabetic patients.

I see no rationale for "farming" these tests out when I can do them myself, send reports to the PCP and/or other specialists are required.

As with any procedure, know your limits and perfom it primarily for the information it provides and not for its reimbursement.

I agree with Dr. Kesselman that ABI is fairly useless in our patients, consisting mostly of DM patients, elderly patients, and dialysis patients. Since they have calcified leg arteries, you get either falsely elevated ABI value or "non-compressible" test.

As with Dr. Kesselman, I am also critical of the PADnet system, as it is based on ABI/PVR, which are both macro-perfusion test that may not help you in predicting the wound healing potential in wound care centers. 

Lastly, I echo Dr. Kesselman's last statement that, we shouldn't be providing any service/tests because it "pays well" without good clinical reasoning. That's a sure way to abuse --> red flag --> audit.

Just my 2 cents.

 

I ignore the ABIs on my PADnet. I look at the waveforms instead. It does have its limitations, but many of my patients see so many doctors and have so many tests, having the machine in my office has been a bit of a convenience for these folks. I DO follow Medicare guidelines to the T. No wish to get into trouble with them.  I just hoped the investment in the machine would have paid for itself. No one likes to lose money on these things.  It also hurts because I have been paying a lease on this so I will essentially lose the equity I thought I was building up in this.

Just a brief suggestion from me,

If you don't need all the bells and whistles, I think you can replace your PADnet with a hand-held Doppler. I use a Koven (Hadeco) brand hand-held Doppler, which has been working great for me for many years. All you need is an ultrasound gel. If you want to bill for your vascular test, however, I recommend a machine with a print-out feature.

So, I have this handheld Doppler and another machine (Sensilase by Vasamed) which is somewhat similar to the PADnet. I use the handheld Doppler when I want a (non-billable) "quickie" test to confirm the DP/PT flow in my patient's assessment. If I suspect any degree of significant ischemia, I may do the SPP/PVR test afterwards with Sensilase, then print out the report, which goes in my chart. 

I just did a quick search on eBay, and there are many listings for handheld Doppler machine for "general blood flow studies" for $100-200.  One example here.  

For each of his/her own... I do happen to know a few doctors love their PADnet system, because it supposedly opens up the communication/referral source from local vascular surgeons. 

Just my 2 cents...  

A 66 year old long time runner presented with claudication of the left limb during running and exercise getting worse.  he went to his DPM and had vascular study of the left leg (only) and was told he had patent circulation, not to worry.
Repeat studies showed less than 50% flow in the left limb when compared to the right and after vascular consultation it was also discovered that he had carotid disease.   He was referred and is being treated medically for now and seems to be doing well.

My point is that, albeit it is difficult because of economic need that continues to be forced on us, we should not accept new income streams unless we first confirm its validity to our patients and secondly, make sure we have the training and skill to deliver the service as well as the practitioner you are denying payment to.

I suggest pretending that there is a lawsuit contending that you were negligent and overstepped your training and experience in delivering a new service and make sure you will be able to defend yourself.

I avoided PAD testing in my office until PADNet because the reading is done by a vascular surgeon who can assume responsibility for the test and followup.  In addition, I deliver non operative care of vascular problems which are often never discussed if the vascular surgeon is the primary diagnostician.  I and my patients remain pleased with my decision.

It would be very interesting to here from some malpractice attny's on this issue, but this is my opinion (as a non attny).

Utilizing PAD net or any other non invasive testing where the DPM performs only the technical component, would likely not  totally relieve you of liabiltiy in a malpractice action. You can be sure that the plantiff's council will alledge that you as a DPM are not competent to perform such a test and  that is why you have a vascular surgeon interpreting the exam.

Perhaps the attny representing the vascular surgeon who did interpret your test would also alledge that his interpretation was based on your exam. This in attempt to deflect or share the liability.

You can also be sure there would be countless vascular surgeons ready and willing to testify against your competence as well.

That being said, if you are trained appropriately, taken a course and referred patients out to others as required,  those allegations should be succesfully defended. Therefore I see no logic in  being reimbursed for only the technical component when you still will have liablity.

There is no excuse for performing a single limb test (with the exception of an amputee). Comparative flow studies between limbs are vitally important.

Dopplers (esp ABI) and PCR in my opinion are no longer the standard of care for determining adequate perfusion. PPG and toe pressures along with doppler wave form analysis are far more accurate (but still not entirely reliable). Duplex, MRA and Angiography are far more predictive of disease.

Most PAD patients do not have isolated PAD and most have caroitid, coronary, renal and perhaps even aortic disease.

As the boy scouts saying goes, be prepared. Get the training required and perform a complete exam. Any significant abnormalities by the non vascular surgeon should be referred out to an appropriate speciailst.

I recently compared he utilization data from 2005 vs. 2008 on CPT codes 93922 (single level non invasive extremity arterial study) and 93923 (multi level non-invasive extremity arterial study). This study reveals the following:

A doubling in the number of single level testing done by all practitioners (317,000 to 604,000) and a 33% increase in the number of multi-level testing done (448,000 vs 692,000) from 2005 through 2008. Podiatrists only accounted for 8.3 % of the single level studies in 2005 and 8 % in 2008 and 3.2% of the multi-level stuides in 2005 vs. 4.9% in 2008. The number of multiple level studies performed by podiatrists tripled and the number of single level studies doubled, however they still remain within the same relative percentage of the total number of extremity testing being performed.

The statistics for podiatry seem within reason for the size of our profession, considering the increasing number of diabetic patients seen by our profession and the increased number of podiatrists providing wound care services.

Before reaching any additional conclusion, one must also consider the huge increase in the total number of non-invasive circulatory testing performed. This includes all vacscular studies of the lower and upper extremities,   carotid and renal scanning, venous, abdominal aortic screening (now covered by Medicare), duplex scanning and echocardiography.

A recent Mescape article (New Federal Report Details Health of US Population; Diagnostic Imaging has Tripled http://www.medscape.com/viewarticle/717183) referenced this very topic.  I don't have access to the data for all vascular testing. It seems logical to expect that the increased number of  non-invasive vascular studies performed by all providers (general practitioners and specialists) are really the driving force behind increased scrutiny of non-invasive vascular studies.

Interesting data! Thank you for sharing your findings with us.

I would like to add something; over the last several years, I believe there is definitely more awareness among medical profession about the prevalence of PAD, Peripheral Arterial Disease; not just only in lower and upper extremities, but PAD can happen in carotid artery, renal artery, and mesenteric artery... basically, anything beyond CAD (Coronary = central) is PAD (Peripheral Arterial Disease). I think it is definitely a positive development that we (US physicians) are collectively utilizing the diagnostic tools more, to our patients' benefit.

I agree with Dr. K; I don't believe for a second that "DPMs are over-utilizing the vascular testing and the Medicare is on our tails." I think they just see the upticks in 93922/93923, and they want to rein on the cost. It's a whack-a-mole thing, I think.

I also want to mention that, we've also come a long way in fixing PAD in endovascular fashion; I go to various vascular conferences for my wound care talks, and I am constantly amazed at the advent of new endovascular devices to re-open the blocked arteries, pretty much anywhere in human body. In our institution, they are replacing the heart valves with endovascular tools (through the femoral arteries), without cracking the chest open. It's truly an amazing feat.

This information applies to WPS.  I am in Michigan and operate an IDTF and ICAVL Vascular Lab.

For more information about compliance with the WPS LCD for Noninvasive Vascular Testing (N.I.V.T.) (L28586)
you may want to contact your Medicare Carrier, health care attorney or if you practice within WPS call the Medical Director at Medicare (listed below).  

To view the LCD goto: http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd_id=28586&lcd_version=14&show=all

Robert R. Ross, PA-C
Triad Diagnostic Technologies, LLC
Point of Care-Peripheral Vascular/Peripheral Neuropathy Studies
President-Clinical Affairs,
Medical Education and Research Development
39625 Lewis, Suite 200
Novi, MI  48377-2972
Office: 248-679-1710
E-mail: bobross@earthlink.net