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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?

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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:


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


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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.

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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.  

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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. 


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