Evaluation of neck masses and cervical lymphadenopathy often requires imaging studies by computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US), and/or positron emission tomography (PET). Most of these scans require that the patient be scheduled at another facility or department to have the scan performed by a technologist, await interpretation by a radiologist, and then return to the ordering physician’s office for discussion of the test results and treatment planning. Often, ultrasound-guided fine needle aspiration may be indicated, requiring yet another appointment for the patient. These multiple visits are not only inconvenient and stressful for the patient, but they tend to tie up the physician’s schedule as well. A recent study concluded that at least one of these modalities-ultrasound-can be successfully incorporated into the office setting, creating a more convenient situation for both the physician and patient, and offering a valuable and efficient diagnostic option.
The study (Akbar N, et al. Otolaryngol Head Neck Surg 2006;135;884-8) focused on the cost considerations and practical strategies for incorporating ultrasound in a head and neck practice. The authors concluded that there are significant benefits to both the patient and surgeon by having ultrasound technology available in the office. Furthermore, they found in-office ultrasound to be cost-effective, with the potential of offsetting the cost of implementing the technology within a year.
Indications and Advantages
Bert W. O’Malley Jr., MD, Professor and Chairman of the Department of Otorhinolaryngology-Head and Neck Surgery at the University of Pennsylvania Health System, has been using in-office ultrasound in his clinical practice for approximately a year. He has found having ultrasound available at the time of his examination is very beneficial in evaluating two types of lumps and bumps in the head and neck region: to further evaluate those he can palpate, and to locate and identify those he cannot palpate.
Dr. O’Malley offers the example of patients with a history of neck surgery with resulting induration making it difficult to palpate the structures. Ultrasound is more sensitive than palpation alone in differentiating between post-surgical changes and lymphadenopathy. Now that he has ultrasound available at his fingertips, Dr. O’Malley uses the technology on all of his postsurgical patients. He feels that routine use of ultrasound in these cases increases his potential for identifying recurrences earlier than if he was to follow the patient with only physical examination and periodic CT scans. It provides the physician with good information for further decision-making in cases where he or she might not have otherwise picked up on or identified something that should require further investigation. Dr. O’Malley states, Theoretically, we can catch diseases earlier, when they’re easier to treat, as opposed to later, when they are harder and more expensive to treat.
The patients love it. We can have kind of a ‘one-stop shopping.’ We can do an exam, we can do an ultrasound, and we can even biopsy.
-Bert W. O’Malley Jr., MD
When ultrasound is readily available and utilized at the time of initial examination, it can sometimes obviate the need for more advanced studies, such as CT, MRI, or PET. On the other hand, ultrasound may indicate that further imaging using one of these modalities is warranted, and the patient can be scheduled for these tests in a more time-efficient manner.
Otolaryngologists can use their expertise in head and neck anatomy to perform more thorough ultrasound examination of the head and neck regions. The otolaryngologist thus does not have to be limited by information provided by written reports and static images of one specific area. Real-time images offer the opportunity for the physician to immediately explore further if indicated.
Another huge advantage to having ultrasound available in the office is the ability to perform ultrasound-guided fine needle aspiration (USFNA) immediately if indicated. This offers a distinct time-saving advantage in diagnosis. The Otolaryngology-Head and Neck Surgery study indicates that USFNA has a 95.7% sensitivity and 92.9% specificity for differentiation between benign and metastatic nodes. The study further suggests that USFNA may, in some cases, preclude the need for neck dissection.
Dr. O’Malley says that his patients find it very gratifying that he is able to give them instant information. Even in cases where further diagnostic testing may be necessary, they appreciate that he is able to give them some level of on-the-spot feedback. He states, The patients love it. We can have kind of a ‘one-stop shopping.’ We can do an exam, we can do an ultrasound, and we can even biopsy.
Equipment and Cost
The physicians who participated in the Otolaryngology-Head and Neck Surgery study advised that the machine used for head and neck ultrasound and USFNA should have a transducer from 7.5 to 12 Mhz, color Doppler, and a built-in camera for capturing images. The authors determined that a system with these specifications can be purchased for between $20,000 and $40,000. There are much more expensive systems available, but the added features of these models are not necessary to perform thorough head and neck ultrasound evaluation. The more expensive models also tend to be larger and less portable than the less expensive models.
Other options for obtaining the necessary equipment can include sharing equipment between specialty groups. If the geographic and scheduling logistics can be coordinated between offices, the sharing of equipment can significantly reduce the startup cost of initiating in-office ultrasound.
Leasing of ultrasound equipment can also be considered as an alternative to purchasing the equipment outright.
Training
Although there are currently no certification requirements for the use of in-office ultrasound, several organizations are in the process of developing guidelines. Organizations including the American College of Emergency Physicians and the American Institute of Ultrasound in Medicine have recommendations in place for education, training, and supervised performance before a physician uses ultrasound independently.
The Otolaryngology-Head and Neck Surgery study identifies organizations which currently offer certification courses for head and neck ultrasound. These include:
- American College of Surgeons (ACS)
- American Association of Clinical Endocrinologists (AACEO)
- Radiological Society of North America
- American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)
The ACS certification program is modular in concept. Participants are required to first complete the basic core module, which is available on CD-ROM. This module covers introduction to the program, ultrasound physics, instrumentation and scanning technique, and clinical applications.
Following successful completion of the basic core module, the physician must then complete the advanced module(s) in his or her area of interest. The head and neck module is an eight-hour curriculum that includes:
- Physics and principles of ultrasound
- Scanning techniques and normal head/neck ultrasound anatomy
- Head/neck ultrasound interpretation
- Interventional head/neck ultrasound
(ACS Web site. Available at www.facs.org/education/ultrasound.html . Accessed January 26, 2007.)
The cost of the ACS certification varies according to level of ACS membership. The cost for the CD-ROM for the basic core module ranges from $90 to $300. The eight-hour head and neck advanced module costs $775.
Dr. O’Malley completed the ACS certification program under the tutelage of Robert A. Sofferman, MD, Head and Neck Module Director. He found the training to be extremely reasonable, easy to learn, easy to apply, and not at all cumbersome. He estimates that following his formal training, it took him only about two months of using ultrasound on his own before he felt very comfortable and proficient at seeing the structures in the neck. He was able to quickly and easily train his nurse and nurse practitioner to set up the equipment and assist him with ultrasound examinations.
Reimbursement
Dr. Akbar et al. concluded that the primary issue regarding proper reimbursement for in-office ultrasound and USFNA is utilization of the correct CPT codes. As with all medical insurance billing, improper coding can result in a significant loss of revenue.
When billing for diagnostic ultrasound and USFNA, thorough supporting documentation is essential, and the images must be retained as part of the patient’s medical record. The authors do caution that ultrasound cannot be billed as a screening tool or as part of the general physical examination.
Based on current Medicare reimbursement for the appropriate CPT codes, the authors of the Otolaryngology-Head and Neck Surgery study determined that if one USFNA is performed per week, and one diagnostic ultrasound is performed each weekday, it would offset a $30,000 equipment purchase and certification cost in one year.
The indications for ultrasound in otolaryngology are well recognized. Because ultrasound is noninvasive, there really are no risks or contraindications to its use. In-office ultrasound can provide otolaryngologists with better information more quickly and reduce the anxiety of patients in a convenient, cost-effective manner. The incorporation of this technology into the office setting offers the opportunity to better utilize it to full diagnostic advantage.
©2007 The Triological Society