Jump to content

Recommended Posts

I started my practice in an ED at a level one trauma center and was informally trained in bedside ultrasound on the job. Over my 3.5 years with the group, PAs were brought into the same rigorous training standards as the EM residents with the goal of securing credentialing for all PAs. I ultimately completed the requisite exams and was technically credentialed at that point.

 

I left that position shortly after and began working with another area organization in EM. Bedside ultrasound is culturally used less as the average practitioner with my current group has less experience, however many of the staff are ultrasound trained. I'm running into issues with ultrasound documentation in that we are allowed to perform the exam, bill and document only if we have a credentialed physician looking over our shoulder while we perform the exam. We have been asked not to document the ultrasound in our note for both billing and medicolegal reasons (understandably). 

 

When this issue for APPs (both PAs and NPs in my new practice) came up, our group was told that it is system-wide policy that APPs can't do or can't be credentialed to do bedside ultrasound. I'm wondering what resources are available to help PAs/APPs develop a credentialing process for bedside ultrasounds within their organization. I see there is a Society of PAs in Clinical Ultrasound, however not many resources regarding this professional practice issue. Can anyone help point me in a direction or offer up their professional experience?

Share this post


Link to post
Share on other sites

I haven't been in your position yet but I suspect I will someday since I also had the same ultrasound training as the physician residents and hope to use ultrasound frequently in the future.  I have been trying to accrue resources in preparation for that day - they aren't perfect but its a start.  I thought the SPACUS website was quite helpful - many of these resources are from there.

 

AMA and ACEP are the big players here.  This is their main page of resources:

-https://www.acep.org/Clinical---Practice-Management/Ultrasound/

-Also check out http://www.spacus.org/credentialing-guidelines.html

   http://www.spacus.org/billing-reimbursement.html

 

Within this, ACEP's ultrasound coding and reimbursement 2009 document - page 116 says: 

Are midlevel providers allowed to perform Emergency Department ultrasounds?

Midlevel providers (ie. PAs and NPs) are subject to state defined scope of practice. Depending on how the state-guidelines above are interpreted, the midlevel providers would also have to be credentialed by the hospital to be performing the ultrasound procedure. Their credentialing process would be expected to meet the same requirements as an Emergency Physician.

If the scope of practice criteria is met and the hospital credentials the midlevel provider, the PA or NP is able to bill for procedures. 

 

So, if you can show that there are no restrictions to ultrasound within your state-specific scope of practice, all you have to do is get credentialed - and ACEP is recommending the same credentialing requirements as physicians, which is described in the other article.  Basically there are 2 different pathways, with the residency model of a minimum 25 of each core scan and total of at least 150 scans with dedicated training.  They word it like this, "The [physician assistant] resident has fulfilled the requirements for competency and privileging in Emergency Ultrasound through the Residency-based Pathway defined by the American College of Emergency Physicians.

They have participated in both didactic instruction and hands-on proctored ultrasounds examinations, and have completed at least 150 documented and reviewed cases for credentialing in limited emergency ultrasound for the following indications: (lists out core indications)."  

 

My residency program wrote a letter to help facilitate future credentialing that basically detailed that our experiences included all of the above credentialing requirements, and it is signed by the fellowship-trained EPs/faculty/ED US directors.  I think it will be very helpful in the future.   perhaps the ultrasound educators at your old ED could write up a similar letter that may have some weight for you as well?   

 

Of course, after being credentialed, there is still issues with billing that aren't quite straightforward.  Must remember to save documented imaging, there are nuances with CPT coding, and knowing how to increase the complexity for upcoding.  ACEP has a lot of resources on their page for this.  

 

Certainly the most knowledgable/experienced person person on this topic is Frank Norman - a forum member with username FiNorman who is the founder of The Society of Physician Assistants in Clinical Ultrasound Spacus.org - he may have further insights / updates and you could try PM'ing him.

 

 

Hope this helps!

-SN

  • Upvote 4

Share this post


Link to post
Share on other sites

Great answer SN..... I apologize for the tardy reply, as I just noticed this post.  My name is Frank, I am the President of SPACUS, which has now morphed into SPOCUS. http://SPOCUS.org.  

 

You should use the ACEP guidelines for credentialing.  I would implore you to please reach out to me if you are refused credentialing because you are a PA.  This is an issue we are diligently working on, and ACEP and AAPA are actively involved with.  Privileging should be solely based on state law, documented experience, and demonstrated competence of clinical practice.  Any other basis for refusing to grant privileges is contrary to JHACO standards. https://spocus.org/Credentialing-Statement

 

If your group or the facility seems to be the ones not supporting your effort or that it is an issue of medical-legal liability I would politely point out that there have been ZERO studies, which ever demonstrated harm to patients from groups of professions performing POCUS.   There are not even any case studies to demonstrate harm done.  In fact, since there is no data on this subject,  there are at least 3 studies which looked at the number of law suits filed in state and federal court related to POCUS.  Over the 20 year period, these authors found 8 law suits.....in each of these cases the breach of duty was alleged to be "a failure to perform the bedside sonogram, thereby violating the standard of care."  

 

Therefore facilities and practices that think they are shielding themselves from liability by not having a program are sadly mistaken.   Since 2007 the ACGME mandates procedural competency in EUS as it is a “skill integral to the practice of Emergency Medicine” as defined by the 2013 Model of the Clinical Practice of EM.  If we practice by the principal that patients deserve the same standard of care, regardless of the provider seeing that patient.  That means for the past 10 years every department in this country has had the time to incorporate this practice into a formalized program and POCUS is the STANDARD of care for every clinician practicing EM.

 

Leadership will have a very long day in court explaining how they failed to incorporate this into the practice with a 10 year head start.

 

As far as state law, I am not aware of any state law that prohibits PAs from performing ultrasound if delineated by their collaborating physician.

 

Dirty secret... there are only 4 states that require licensure or certification for ultrasound techs to perform ultrasound studies.  New Hampshire, New Mexico, North Dakota, and Oregon.  None of these states require licensure or certification for physicians or PAs (however NM requires nurses, of which nurse midwives fall into the category... therefore NM in this state were forced to take a certification exam to perform ultrasound).  

 

These states allow physicians and PAs to perform POCUS, as they are exempted from the certification requirement as medical providers.

 

SPOCUS would be happy to assist you with credentialing.

  • Upvote 2

Share this post


Link to post
Share on other sites

I should have added... if anyone practices in another specialty and is having trouble getting credentialing use the generalist https://spocus.org/Practice-Guidelines.  

 

I would also ask that you please reach out to me and let's communicate.... the AAPA is looking for examples of PAs encountering barriers to practice and your situation can help out others.  

  • Upvote 1

Share this post


Link to post
Share on other sites

Where I work its PA-only in the ER (love rural medicine), and if you aren't ultrasounding patients at the bedside, you just aren't meeting standard of care in many scenarios.  I too went through a Level 1 /Academic Center's residency U/S program to get my credentials while I worked there, and it was expected of us to use it there as well as every other job I have had.  What you are dealing with sounds like a physician/hospital credentialing/turf issue - and there is no rational basis for it on their end. 

I would be extremely leery of performing a POCUS and not documenting it.  If you do it, document it.  If you can't do it per policy - don't do it.  Should something ever happen and you end up in a lawsuit, you don't want to be sitting across from a plaintiff who swears you put an U/S probe on them but its not documented anywhere. 

G

  • Upvote 1

Share this post


Link to post
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.

Guest
Reply to this topic...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.




  • Similar Content

    • By monae622
      Hey everyone!! 
      Hoping to get some insight on my offer for a position at a Level II trauma center in SoCal. I worked with this group of surgeons as a student so I know it would be an excellent learning environment and tons of good exposure. My time will be split weekly, working in trauma + gen surgery one week and strictly in ICU the next. Training will include running traumas, first assist, various procedures, ICU and vent management, etc. No surgery residents. They currently have 3 NPs and 1 PA and are looking to expand. 
      Base salary at $110k.
      Hours/call: 40hr/week, leaving promptly at end of shift. No overnight shifts as new grad until myself and SP are comfortable. Contract states that call will be paid "standard on call fees" but does not state exact amount. They did stress that being on call is not likely, esp as a new grad.
      Benefits: Health insurance, they pay 90% of standard costs. Have to pay for my own dental and vision. ( is this normal?) Malpractice insurance covered- will be sure to ask about tail coverage. Not eligible for 401k plan until 1 full year of employment!! Seems a little odd to me, thoughts? 
      PTO: "employee shall accrue 0.05 hours of PTO for every 1 hour of work performed" which if my math is correct comes out to about 10 days of PTO -_- hoping this is a typo because that's extremely low. The APPs currently work 4 10s a week but will likely move to 3 12s as more APPs are hired so I am not sure how this affects the amount of PTO. I am thinking of asking for 4 weeks PTO to include vacation, sick and CME days. 
      CME: $1500, does not state specific number of days off 
      Overall, I am really happy with the offer as a trauma position has been my dream for a long time! Not so happy with the PTO, but believe they will be willing to work with me! I would greatly appreciate your thoughts!
    • By viveksivaraman
      Hey PA Forum, I am Pre-PA, please don't kick me out, as I wanted to know from PAs what they think about the field, and where my feelings in the application process stand. I went through my undergrad with not much of a direction, graduating with a BS in Biochemistry but a 2.86 GPA. I worked for 2 years as a "scientist" but I was really just running samples through a machine (medical device) and it did not allow any sort of interesting work. I worked as part of the lab at the Boston Marathon, analyzing runner blood samples in the device, and it was the first time I was exposed to the medical field. This allowed me to appreciate their work, and also, for the first time, feel I could make a difference with my efforts. I capitalized on this excitement, and looked into nursing and PA, and decided PA. I got an EMT certification, and gave CPR to a patient in a trauma room at the nearby hospital as part of the certification. I was so excited, and then I got a job as a CNA in a teaching hospital on a heart failure floor. Everything was coming along. I was also taking pre-reqs this whole time, I completed A&P I,II, Genetics, Biochemistry, all either A or B+. As I worked at the hospital, I mainly bathed patients, and provided care in daily living, working under nurses. But the attitude of the nurses really got to me. Some would bully the technicians in a way, it was never intentional but I could not stand them. All the technicians and nurses were gossipy women and I, more of an introverted male, just felt nothing in common with them, and everything I did was judged. Nurses, and techs and female patients would occasionally hit on me, and it just felt uncomfortable. It became so frustrating for me that these shifts became almost me vs them, in my head. But I kept pushing on, I kept searching for jobs in the ER, because that seemed so exciting to me. I shadowed a resident in the ER, and loved every minute of it. I really enjoyed it because it was exciting; very different than anything I had seen; the machinery of the body was in a life threatening situation, and it was very rewarding to fix it. I also really loved all things space, and always was researching things about space. However I wasn't able to get a position in the ER, and I just felt like the oddball out all the time; and the feminine and social aspect of medicine was driving me nuts. I felt like everywhere in healthcare was this; and had this veneer or being the savior for patients, I just felt I was beating up the wrong tree for my own goals. I shadowed 5 PAs, and enjoyed the ER experience the most. I decided I wanted to try something in engineering due to my love of space. So after 9 months of being a tech, I moved to Houston, with my sister (couldn't go home, father is an alcoholic and made life at home toxic). I decided to try everything I enjoyed to figure out if this field was for me. I started taking engineering classes, a geology class, and started to learn programming, and am volunteering in a lab where I help a professor research bacteria on the Space Station. I have been stressed out, figuring out if this career is for me. I went to healthcare career fair, and interviewed for an ER Tech job, to try it out again, and am hoping it is less daunting on me. I also am thinking about pursuing biomedical engineering, as it may combine my interests, but I am nervous, because it seems a bit antisocial. I was wondering if I could get some advice about my situation, and if I have it all wrong about actually being a PA. Thanks!
    • By SEMPA
      Registration now open for SEMPA 360 being held April 14-18, 2019 in New Orleans, Louisiana!
      Come learn from the best educators in emergency medicine. Conference favorites include Kevin Klauer, Amy Keim, Haney Mallemat, Michael Winters, and Richard Cantor to name a few. The EM:RAP team will also be joining us again in New Orleans for a day of learning along with a special meet-and-greet to visit with some of your favorite EM:RAP stars!
      Over twenty workshops will give you the skills needed in emergency procedures, airway management, ultrasound, slit lamp, suturing, x-ray interpretation, teaching, ECG interpretation, and more!
      Over 40 lecture sessions will cover topics such as critical care, trauma, pediatric emergency medicine, ophthalmology, cardiovascular emergencies, GI disorders, infectious disease, literature updates, and high risk emergency medicine.
      There are also plenty of social activities to enjoy with old and new friends. A wine and cheese reception, opening party at Mardi Gras World, and the SEMPA Quiz Bowl competition will welcome you to the EMPA event of the year.
      CME is available for PAs, physicians, and NPs.
      The discount for early bird registration ends Feb 13. The hotel room block is also limited so sign up now!
      For more information:
      https://www.sempa.org/sempa360
       

    • By UCSF Fresno
      The University of California San Francisco (UCSF) - Fresno Emergency Medicine PA Residency is accepting applications for the 2019 application cycle. This 18-month postgraduate program, affiliated with the UCSF School of Medicine, is designed to prepare PAs to practice in a variety of emergency medicine environments.
      We will be accepting 2 residents in 2019. The class will start June 26, 2019 but we will be offering rolling admissions into the Fall for accepted applicants who have a later PA school graduation date. 
      Deadline to apply is January 15, 2019. 
      Rotations include:
      Trauma Critical Care Pediatric Emergency Medicine Burn Orthopedics Dermatology Ophthalmology Oral Maxillofacial Surgery Toxicology Emergency Ultrasound Anesthesia EMS  Resuscitation courses include: ACLS, ATLS, BLS, PALS
      18-month stipend: $90,000
      Benefits include medical, dental, vision, life insurance, disability insurance, 401k, employee assistance program, 4 weeks of vacation, membership in the Society of Emergency Medicine Physician Assistants (SEMPA), UCSF email access, textbook, malpractice coverage, and more.
      Paid travel to SEMPA 360, SEMPA's annual conference.
      Our state-of-the-art ED at Community Regional Medical Center serves as the only Level 1 Trauma Center/Burn Center for Central California, and handles an annual ED volume of over 110,000.
      The Department of Emergency Medicine hosts fellowships in Emergency Ultrasound, Medical Education, and Wilderness Medicine. Our faculty are involved in EMS, wilderness medicine, ultrasound, medical education, toxicology, international emergency medicine, and more. They are also leaders in the emergency medicine and EMPA community.
      For more information, please see the attached flyer.
      Website: http://www.fresno.ucsf.edu/emergency-medicine-physician-assistant/

      Email: em.pa.residency@fresno.ucsf.edu
      Residency Flyer.pdf
×
×
  • Create New...

Important Information

Welcome to the Physician Assistant Forum! This website uses cookies to ensure you get the best experience on our website. Learn More