Australian General Practice, Medicare and Ultrasound Machines
This guide was written in response to several requests for information on the Australian general practice craft group GP’s Down Under. There seems to be good interest in how GP’s could start to get interested in ultrasound, discussion around choosing a machine and whether or not there are Medicare rebates for any ultrasound imaging.
Unfortunately as well as enthusiasm, there has also been significant misinformation with myths such as:
– only rural GP’s can access Medicare rebates for ultrasound
– Rural GP’s can only access Medicare rebates if they are 100km away from a radiology clinic
– No GP’s can access Medicare rebates
– GP’s can access Medicare rebates but they have to have completed the DDU (Diploma of Diagnostic Ultrasound provided by ASUM (Australian Society for Ultrasound in Medicine) or the CCPU (Certificate in Clinician Performed Ultrasound)
– Ultrasound does not add anything to GP consulting
-GP’s both rural and urban can be registered so that their pt can access a MBS rebate for ultrasound scanning in your rooms
– There is no distance requirement
– You do not need a particular DDU, CCPU or other specified training, although training is an excellent idea
– An ultrasound machine can add income to your practice and extend your practice which expands you experience, challenge and satisfaction
So as at March 2018 in Australia, what is possible, what is safe and acceptable and what makes good business sense?
Point of Care Ultrasound (POCUS) has been exploding in hospital and pre-hospital care with increased use in the emergency department, theatre, ICU and paramedic and pre-hospital care. This is due to dropping cost and complexity of machines, desire to avoid ionising radiation and the benefits of being there with the patient when scanning and then having this information guide your care. “Does this hurt when I press the probe over this gall bladder?” POCUS is also introducing non-traditional uses of ultrasound to medical care that are never done by sonographers and radiologists. A sonographer will never ultrasound a lung but this is now my main use of the machine which can help discern CCF from COPD from pneumonia. A sonographer will never assess the optic nerve diameter as a proxy for rising intra-cranial pressure or scan the eyeball looking for the “washing machine” appearance of retinal detachment. POCUS is different from a formal ultrasound – often just one question is answered to allow action (which may include referral for a formal ultrasound).
Primary care/General Practice will join these ranks for POCUS uptake again as machines get easier and lower cost. It behoves us to get on board this push as medical students are having POCUS integrated into medical school (Monash university students in Melbourne Australia are doing this) and we risk being left behind. There is also a significant benefit with extending your practice and remaining interested in medicine and demonstrating your innovation to the patient. I love this slide from a conference, taken from Twitter about surviving disruption in medicine:
Accessing MBS items for ultrasound
The MBS has a number of items that are called the non-referred ultrasound items. A referred item is what a mainstream radiology provider would use if you referred a pt to them – such as item 55036, ultrasound of the abdomen, paying $111 in March 2018 or item 55700 pregnancy less that 12weeks, paying $60 in March 2018.
However the item numbers that GP POCUS users are interested are the non-referred items. These are items like 55037 – Abdomen when non-referred, paying $37.85 in March 2018 or 55703 pregnancy less than 12weeks when non-referred , paying $35 in March 2018.
Access to non-referred items is not automatic!
These non-referred MBS items are billed separately to your usual Medicare provider number. What is required is a location specific Provider Number (LPSPN) that is tied to the machine at a specific location and not a doctor. The first part of this application is very easy – the paperwork completion of the LSPN application with Medicare. In due course they will send a location specific provider number to you. A catch is that you need to confirm that you desire to update this every year although all that is required for renewal of the LSPN is an email, you don’t need to complete the forms again.
The next stage is accreditation of the machine with DIAS (Diagnostic Imaging Accreditation Scheme – Dept Health). This process seems to be like conveyancing for a house – you could maybe work out how to do it yourself but hopefully you only need to do it a few times and the time saved in paying someone else to do it and get is right is worth it. I have not heard of individual doctors completing their own, if you do, get in touch. Everyone seems to use the equivalent of a conveyancer – an accreditation service. These services also accredit formal radiology services, general practices and other health clinics.
There are seem to be four groups that can accredit you – HDAA, National Association of Testing Authorities., QIP and Choice Accreditation and help you apply through the DIAS process. Talk to the group that accredits your practice – they may offer to “bundle” accreditation.
Perversely, none of the accreditation process is about you ability to use the ultrasound machine, interpret images or use the information to manage the patient. Correspondingly, no particular training or diploma is required as evidence for accreditation. Obviously training and acting within your scope of practice is excellent safe medicine, which I will cover below. However for the LSPN and accreditation of the machine, no particular training is needed. Accreditation requires proof entirely of bureaucratic processes – complaint handling, where manuals are stored, how results are communicated and how pt identification is ensured. This is an example of a table of contents of an accreditation manual:
The accreditation company will have pro forma for most of this and will ask you questions about what is the machine serial number, where the machine is stored, how patient details and US reports are stored, how a pt can make a complaint, how a pt consents and how pt identity is confirmed (three items min – name, DOB, address). If you will be using trans-vaginal probes you also need to create a written consent form and demonstrate what decontamination process you will follow.
After accreditation has gone through, your LSPN will be registered for the machine, at that location. This single provider number obviously does not differentiate between providers so you will need a local policy to understand who charged what if more than one GP uses the machine. LSPN can all be searched online. Don’t forget to reply to your yearly LSPN details update from Medicare. Unfortunately accreditation of the LSPN for DIAS needs to be re-visited three yearly.
I called HDAA, they suggested $498 for the first two years then you pay for the full accreditations $1600 which covers you for the next four years. When I called them HDAA stated you could also pay $405 yearly from the first year, every year which averages things out. Calling QIP they suggested $545 for the first two years then review in 4 years for the full suite, then every 4 years after this. There is no on-site requirement for accreditation everything being completed over email.
Too much paperwork!
Of course there is no requirement to go through this DIAS process. You can choose to not bill or privately bill the pt only around use of the ultrasound machine. Much like a dermatoscope, you can accept that the ultrasound improves you diagnostic skill and adds quality to the consultation without adding directly to remuneration. There are tax deductions and depreciations available that can lessen the sting.
Currently there is no training requirement to access DIAS. However there may be local requirements – this is common in Emergency Departments. Obviously like any skill in medicine there is a requirement to obtain and maintain proficiencies . Ultrasound is much like endoscopy to my mind – a combination of physical manipulation, applied anatomy and interpretation while your eyes are looking at a screen, divorced from what you hands are doing. This challenge is best learnt from a quality provider and repetition. In Australia the RACGP provides some one day Active Learning Modules. Dedicated training is provided by Australian Ultrasound Training, Ultrasound Village and Australian Institute of Ultrasound. The benefits of these organisations is exposure to disparate machines before you make your choice, access to model patients such as pregnant women and phantoms (ultrasound training mannequins). An area that will likely expand is training using VR such as Microsoft’s Hololens.
Currently you can decide your own scope of practice and what you are comfortable with. For example I am confident and comfortable with assessing and ruling in an Intra-uterine pregnancy if it is there. However I do not have the skills to comment on ovaries or in the setting of a positive pregnancy test and empty uterus to fully assess for an ectopic pregnancy. These people go off for an referred scan to a radiology provider.
How will purchasing and using your machine be regard by your medical insurer? This is where the issue of scope of practice comes in. Could you demonstrate appropriate practice within expectations of your peers? Can you demonstrate training? ASUM is moving to influence POCUS as it does for sonographer ultrasound. There is one coroners case that I am aware of involving POCUS – the very complex death of Mrs Dhu in detention in WA. The expert witness although not reagarding POCUS negatively (at least in the condensed coroners report) suggests a CXR should have be completed rather than just POCUS.
Being disciples of GPDU and Business for Doctors we believe in the power of FOAMed. There are excellent resources available:
https://gppocus.com – myself
http://5minsono.com – great quick bite tutorials
https://ddxof.com/ultrasound-in-dyspnea/ POCUS flowchart in dyspnoea
http://sonospot.com tutorials and apps
http://pocusjournal.com does what is says on the box
http://www.medicinec.si/projekt/ultrafest/ eFAST and other charts
http://scghed.com/ed-orientation/ultrasound-where-do-i-start/ US village collective
Twitter suggestions to follow
@gppocus – myself natch
@UTS_Australia @gabyblech @antwaldecho @PURE_Updates @UltrasoundMD
Choosing a machine
This is an area that is changing quickly. Historically machines were large cart based units made by traditional electronics companies – General Electric, Toshiba and Siemens. Machines then became smaller and portable with Sonosite, Mindray and then reverse engineered companies Sonoscape, Chison getting involved. The field is now exploding with pocket sized machines – GE Vscan, Sonosite iViz, Clarius and the announced but not delivered Butterfly. It is not clear to me if these app based machines would qualify for LSPN – all the users I know have laptop sized or larger machines with swappable probes.
In the files of BFD there is a worksheet from April Armstrong around a possible business case for your machine if you are a member, there has also been group buys in previous years.
As well as the actual machine, there are other considerations:
– Do you move clinics frequently? Consider size/weight, fragility
– Will you store images on clinical software? Does the machine export wirelessly or via USB? Does it export via .jpg/.avi/.mpeg?
– Do you need a printer – probably not, thermal paper images impossible to scan to pt notes, unless you need to give pt images.
– Do you need a specific stand/trolley? Probably not – ergonomics different compared to a sonographer scanning all day, not moving machine much.
– If you need a trans-vaginal probe, how will you ensure decontamination? (three options for small clinics- Tristel wipes kit, cidex-OPA (aldehyde based) liquid and Revital-OX solution (peracetic based) We use Tristel.
– Some machines now sold have software restrictions about which probes it will accept – can this be expanded later? At what cost?
– Is there a mandatory service pack? Warranty of unit/probes?