Re: Look at the cervix!
From: James Smeltzer (James.Smeltzer@wellstar.org)
Sat Mar 8 13:35:59 2008
Art:
You are right. It is ALWAYS the right thing to do, when you do not know what to do, to ask the patient. Some are resistant to TVS.
THIS IS AMERICA - despite the current administration and Freedom is more important than life.
JimS
>>> art fougner, md <evsono@pipeline.com> 3/8/2008 2:18 PM >>>
Jim
Despite your emphatic plea for cervical evaluation, the evidence is far
from clear as to what to do when you find something. That, imho,
prevents routine cervical length from becoming standard of care. For
myself, I find that in most situations, the cervix is visible with an
empty or partially filled bladder. When I suspect a problem, or when I
can't image the cervix abdominally, I'll explain to the patient that I
need to view the cervix vaginally.
Art
At Sat, 8 Mar 2008, James Smeltzer wrote:
>
>Hi!
>
>I was against the TVS code in the first place, when we were discussing it initially in the OB sig of AIUM or US sig of SMFM. The theory being that the modality was secondary (trans-labial, trans-vaginal, trans-abdominal). It is more work. Andersen showed that TVS is better for cx. Before that was available I and others showed that trans-labial was better than trans-abdominal for looking at the cervix.
>
>I don't know what others do but we provide a full first trimester scan with a 76813, which we bill only if we do nose bone and NL studies. When my sonographers are confident at looking for TR then we will include that. I notice that others are charging for a fetal echo when they do this screen. I am unsure who or what is "right" in this. We did doppler studies and nuchal lucency screens in appropriate GA screening studies for years in appropriate GA and still do with no code or reimbursement.
>
>I believe that we have a duty to provide the patient in front of us with the study that is the best we can do for her. Although the point could be argued that the families of babies with increased NLs who did not have aneuploidy or a heart defect were not helped by information that they did not ask for, I have not heard them express that view. It is my personal opinion that the RVUs for a lot of these early studies are screwed up, and the trend for increased obesity is true but balanced by better technology in the equipment we use.
>
>As for cervical length WE MUST DO IT! IT SAVES BABIES! If the combination of second trimester study and TVS as a "routine" study needs to exist before you do what is right, which is look at the cervix by whatever means works, then I understand your point of view, but I cannot agree with it. I DO have a better position with all this than you do. The majority of my patients are cash-paying poor people who pay a flat rate that includes whatever they need - which makes my work easier. If anything should be included in their study then it is.
>
>Good to hear from you!
>
>Jim
>
>--
>James S. Smeltzer, MD, FACOG, SMFM
>Consultant, Maternal Fetal Medicine
>Wellstar Physicians' Group
>Northwest Women's Care
>787 Campbell Hill St
>Marietta GA 30060
>James.Smeltzer@wellstar.org
>VM 678-290-3035
>Off 770-528-0260
>Page 404-318-3451
>
>>>> <jworrall@alaska.net> 3/7/2008 11:32 AM >>>
>
>OK, I shall stir a bit. I do NT but find it is very time consuming. As our
>patients become more obese, it becomes more and more difficult. I have not
>bothered becoming certified in the nasal bone, because I did not think it
>was worth the money and effort, and it would just make scans all the more
>time consuming. And while I am at it, let me ask a question. Do you
>recognize that 76813 and 76817 are different? If a patient is sent to you
>for "nuchal translucency", or "first trimester genetic screen", do you do
>anything besides CRL and NT? Do you ever charge both 76813 and 76817? If we
>are not allowed to discuss these things, then do not respond.
>
>I do not check all cervices at 18-32 weeks. I do not require a full bladder
>for transabdominal obstetrical scans and I do not see the cervix well
>transabdominally in most patients. I am of the school that the only way to
>look at the cervix is transvaginally. I also am of the feeling that I should
>not charge for exams that were not formally requested by the referring
>provider. I do not want to do a transvaginal scan routinely, without
>compensation of some sort. It is quite a bit of work and time for my nurse
>to sterilize the transvaginal probe. I agree that the cervix should be
>checked, but isn't it up to the obstetrical provider to order that? I guess
>if one has all obstetrical patients arrive with a very full bladder, you
>will be able to evaluate the cervix transabdominally in many patients. Then
>it is not a problem. Still, there is hardly a week goes by that I do not
>have to scan at least one patient that weighs 250-300 lbs. The vast majority
>of pregnant patients I see weigh more than I do. It is becoming a huge
>problem.
>
>I have missed your always-significant contributions, Jim. Please do not give
>up on this forum. Another forum to look at is Yahoo Group's Medical Imaging
>forum. http://health.groups.yahoo.com/group/medicalimaging/?yguid=7595043
>
>Allen
>
>--------------------------------------------------
>From: "James Smeltzer" <James.Smeltzer@wellstar.org>
>--------------------------------------------------
>--------------------------------------------------
>--------------------------------------------------
>Sent: Friday, March 07, 2008 5:48 AM
>--------------------------------------------------
>To: "Multiple recipients of list ULTRASOUND" <ultrasound@mail.obgyn.net>
>--------------------------------------------------
>Subject: Ultrasound forum??! Help Me! Stir the pot!
>--------------------------------------------------
>
>> This used to be a place I loved to go to. Things got very busy. Personal
>> issues intervened. Too many emails from someone hunting a job & Pfft?!
>> Resurrection!?
>>
>> Maybe this pot needs stirring!
>>
>> Hop y'all are doing NTs and nose bones at 10-14 weeks, and checking
>> cervixes at all 18 to 32 week studies!
>>
>> If not, then I would love to hear why not?
>>
>> Is anybody back there?!
>>
>> ;^) Jim S
>>
>> James S. Smeltzer, MD, FACOG, SMFM
>> Consultant, Maternal Fetal Medicine
>> Wellstar Physicians' Group
>> Northwest Women's Care
>> 787 Campbell Hill St
>> Marietta GA 30060
>> James.Smeltzer@wellstar.org
>> VM 678-290-3035
>> Off 770-528-0260
>> Page 404-318-3451
>>
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>________________________________________________
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>________________________________________________
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--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
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