ULTRASOUND Messages for July, 2002: Re: Level three sonogram. Perinatologists vs. Prenatologists

Re: Level three sonogram. Perinatologists vs. Prenatologists

From: Allen Worrall

jworrall@alaska.net

Fri Jul 19 12:34:50 2002

Allen

> ----- Original Message -----
From: David Nyberg, M.D. To: Multiple recipients of list ULTRASOUND Sent: Friday, July 19, 2002 8:07 AM Subject: Re: Level three sonogram. Perinatologists vs. Prenatologists

I have enormous respect for perinatologists and obstetricians. They work hard and they are very good and what they were trained to do. However, I have learned that their training may not necessarily include being very skilled at ultrasound. They have a lot of material to learn and do, and they simply can't spend enough time in ultrasound to be skilled, unless that is all they do. A good perinatologist is not necessarily a good 'prenatologist'. Besides ultrasound, their training in genetics is also generally limited. It has to be, unless they also take subspecialization training in genetics. Having said that, in some geographic areas they may be the most skilled at ultrasound and be the most knowledgable in genetics, and so assume those roles as a referral source. Smart perinatologists will recognize their limitations and get the most qualified people doing their respective jobs. For example, we work closely with the perinatology group in Seattle but continue to do the referral and screening ultrasound exams. The large perinatal group on Phoenix hired an outstanding radiologist/ sonologist in Harris Finberg to do their referrals scans. On the other hand, I agree with Roger that other perinatologists do referral scans with limited expertise or may rely entirely on skilled sonographers and set themselves up as the local referral source. Unfortunately, many referring physicians do not know this and may mistakenly believe that the perinatologists are also the best at making prenatal diagnoses. Insurance companies also seem to recognize a higher quality scan for perinatologists. In the absence of other qualifications or credentials for a prenatologist, who can blame them? I know for a fact that some perinatologists are billing at a rate of $600 per scan. I also know that there is a national movement a foot to allow perinatologists to bill and reimburse at a higher rate, so again I agree with Roger.

> ----- Original Message -----
From: roger sanders To: Multiple recipients of list ULTRASOUND Sent: Friday, July 19, 2002 8:02 AM Subject: Re: Level three sonogram

You are correct that the level two concept started with the AFP program. Why don't the level 2 and level 3 concepts go away even though they have been condemned for years and organisations have tried to replace them with "targeted or referral" sonograms? I believe it is because the level concept serves a valuable purpose. The level one standard refers to the standard obstetrical sonogram as defined by ACR,AIUM, ACOG guidelines which we all know is the minimum legally acceptable level. We know this is not a sufficiently detailed study to rule out anomalies and that greater detail and skill is required for an anomaly scan. It isnt realistic and it is why standards are so variable in this country to think that anyone can do a more detailed anomaly scan which is what the terms "targetted scan" seems to suggest. Currently the only way of knowing who does a quality job is by repurtation. Numerous perinatologists are setting up with limite! d scanning skills to do referral scans. Some type of quality control whether by looking at results to see how often an anomaly is detected at birth or by a sophisticated accreditation scheme for individuals not labs is needed so that insurers know who deserves to get a higher payment for doing a sophisticated exam. without some sort of validation this new code will be an excuse that everyone will use to increase charges.

-- Allen Worrall <jworrall@alaska.net> wrote:

Dianne, excellent remarks about reimbursement.

Regarding level one and two, I think those terms originated when the State of California started its MSAFP program. Some patients required a more comprehensive exam depending on the results of their screen and I think the State of California, since they were paying the bills, designated these two levels, and indicated who could do and be paid for a level 2 exam. Then, as you indicated, the less well trained or less interested practitioners of ultrasound began to say, "well, I am not culpable for missing that, because I was doing only a level one scan".

The editorial by Dr. Roy Filly explains it very well.

Allen

> ----- Original Message ----- From: "Dianne Walkup" To: "Multiple recipients of list ULTRASOUND"

Sent: Thursday, Jul! y 18, 2002 8:14 PM Subject: Re: Level three sonogram

> Greetings, The level one, two and three labels are old and never made any > sense in the first place. Im my opinion, a level one is an simply a poor > excuse for not knowing what you are doing. The old monikers, however, meant > that a level two was a comprehensive anatomy survey, and a level three was a > fetal echocardiogram. > Regarding the charges for these exams; as an expert high risk obstetrics > Sonographer working for perinatologists that know OB ultrasound, we get > reimbursed no more than the people who have no business picking up a > transducer do. As two cases in point from this week alone: one was a > referral because " the fetus is breathing and may be in serious distress", > this was a 35 week normal fetus. Breathing motion is of course a welcome > occupation for a 35 week fetus. Another this week was the one where th! e OB > doc told the patient a week ago that both of her twins were "doing just > fine, and here is one sucking his thumb and the other one grabbing its > foot". We found only one baby at 18 weeks gestation with no evidence of a > second. The referring doc said simply "I made a mistake." > Needless to say, I will welcome being able to charge (and maybe even be > properly reimbursed) for my standard exam which is always a comprehensive > anatomic survey when the new CPT codes are in effect. > Dianne Walkup, RDMS, RDCS > mitakuye oyasin

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