Hospitalists increasingly utilize point-of-care ultrasound (POCUS). While comprehensive ultrasound examinations evaluate all organs in an anatomical region, POCUS is intended to answer focused questions. For example, an abdominal POCUS may only address the presence or absence of intraperitoneal free fluid.
Many internal medicine residency training programs now teach POCUS techniques and interpretation. Recommended training for practicing hospitalists and internal medicine residents includes ultrasound physics, machine operation, image acquisition, and interpretation. Credentialing by the clinician's organization is necessary. External certification of competency is currently unavailable for most practicing hospitalists. Hospitals should have quality assurance programs, carried out by an individual or committee with expertise in POCUS.
In the selection of POCUS equipment, the ability to easily archive and retrieve images is essential for quality assurance, continuing education, institutional quality improvement, documentation, and reimbursement. On occasion, archiving may not be possible, in which case the clinician should document the reason for the lack of a record.
The most common POCUS examinations typically performed by hospitalists are cardiac, pulmonary, abdominal, vascular, musculoskeletal, procedural-assist, and multisystem studies. Cardiac POCUS can assess left and right ventricular function, chamber size, valvular structure and function, central venous pressure, and pericardial effusion. Pulmonary studies can evaluate pleural effusions, interstitial and alveolar abnormalities, and pneumothorax.
Vascular studies may be used for abdominal aortic aneurysm and deep venous thrombosis. Musculoskeletal POCUS can evaluate cellulitis, abscesses, joint effusions, and fractures. Multisystem POCUS is typically employed for shock states, dyspnea, acute renal failure, or resuscitation.
Procedures commonly guided by POCUS include central venous catheters, peripheral venous catheters, arthrocentesis, thoracentesis, paracentesis, arterial line placement, lumbar puncture, and abscess drainage.
Three documentation components are required for reimbursement: medical necessity, a written interpretation, and image capture and storage. The medical necessity or indications for the procedure must be clearly stated and meet the Current Procedural Terminology, 4th Edition (CPT-4), descriptions of the corresponding code assigned.
A separate written report and interpretation of a diagnostic POCUS examination must be maintained in the patient's medical record. When ultrasound is used for procedural guidance, the guidance component may be included in the report of the procedure. The report of a diagnostic POCUS examination should include:
- 1. Date and time of examination
- 2. Name and hospital identification number of the patient
- 3. Patient age, date of birth, and gender
- 4. Name of the person who performed and/or interpreted the study and clinical findings
- 5. Indication for the study, its scope (complete vs. limited), and, if a repeat study, whether it was performed by the same or a different clinician
- 6. Impression (including when a study is nondiagnostic) and differential diagnosis, as well as the need for follow-up exams and incidental findings
- 7. Mode of archiving the data (where the images can be located for review)
The diagnosis should be based on the POCUS results. If it does not yield a diagnosis or was normal, the signs, symptoms, and/or conditions that prompted the study may be used as the diagnosis.
Image capture is required for all diagnostic POCUS examinations and when ultrasound is used for procedural guidance. The orienting anatomy should be labeled, and permanently recorded images must be maintained in the patient record. Images can be stored as printed or digital images. CPT-4 does not require a certain number of images but does require that the images captured reflect the reported findings. Images must be available for payer audits, training, quality assurance, and professional liability purposes.
Current practice suggests capturing one image in each orthogonal plane of each relevant structure, or in the case of echocardiography, one image of each of the classic windows and levels. For needle guidance, it is not necessary to capture an image of the needle in the target, which might cause a distraction posing a procedural risk to the patient. It is enough to capture an image of the relevant point of interest and record a procedure note stating that the needle placement was guided and visualized.
Next month's column will address the coding practices and requirements for POCUS.
Special thanks to Benjamin Galen, MD, FACP, for recommending this subject and for his assistance and suggestions in composing this column.