SVT Comments on a Proposed LMRP
Louisiana

This letter can serve as a model on commenting on a local medical review policy (LMRP). Because all proposed LMRPs will vary to some extent, you will need to adopt this model to your specific situation.

Read the response to the letter to see how your comments can make an impact on LMRPs.

12 December, 2000

Lynn Hickman, MD
Carrier Medical Director, Louisiana
P.O. Box 98501
Baton Rouge, LA 70884-9501
FAX: 225-231-2277

Dear Dr. Hickman:

First, on behalf of the Society of Vascular Technology (SVT), we want to thank you for the dedication and leadership you have demonstrated in serving the Medicare beneficiaries of Louisiana. We want you to know that we, too, are committed to serving Medicare beneficiaries. It is because of our shared commitment to serve these patients' best interests that we are writing to express our belief that the policy recently published in the November 2000 Medicare Provider News, that would appear to require more than general supervision for basic ultrasound services, is inconsistent with existing national policy, as expressed in a program memorandum that the Health Care Financing Administration (HCFA) is preparing, and the national standard of practice. Furthermore, the proposal may have the unintended effect of undermining access to medically necessary testing to Medicare beneficiaries.

SVT, founded in 1977, is a professional society for vascular surgeons, nurses, and technologists, completely dedicated to the advancement of noninvasive vascular technology in the diagnosis of vascular disease. SVT is comprised of more than 3,700 members.

Mr. Terrence Kay, Director, Division of Practitioner and Ambulatory Care, of the Health Care Financing Administration (HCFA), has recently announced that HCFA will be publishing its general supervision rule for basic ultrasound services as part of its national payment policy initiatives. Since this standard would supersede the policy that has just been published, SVT urges that the LA IDTF policy should be changed to be in accordance with federal HCFA policy.

Many vascular, neurology, obstetrical, and cardiac practices performing quality in-office ancillary ultrasound and other ancillary services will literally find it physically impossible to comply with a direct supervision requirement. Unlike other specialists, vascular surgeons, neurologists, obstetricians, gynecologists, and cardiologists still often practice in very small groups of one or two physicians. Most of these specialists spend their days shuttling between various places where they provide critically important medical services. Because they typically practice in small groups, these physicians are physically unable to be present in the office throughout the day when ultrasound and other designated health services are provided.

Nor is direct supervision required for the ancillary procedures that SVT members provide. Except in the case of certain services, such as cardiac stress testing, ultrasound imaging is safely and effectively provided without a physician's presence in the office suite at the time that the service is provided. Moreover, the quality of the testing cannot be improved by having a physician present in the office suite at the time that ultrasound testing is provided. The quality of the testing is dependent on the knowledge, skill, and experience of the technologists who perform the technical component of the study. The physician's role is to render a medical diagnosis of the images created and the data collected during the course of a study performed by the technologist. Although physician supervision is an important component of the interaction between physician and technologist, that interaction simply does not require physician presence in the office suite at the time that most studies are performed.

Accordingly, an inflexible definition of direct supervision will add nothing to the quality of the service provided. Under direct supervision, physicians are not obligated to and do not, as a practical matter, actually go into the examination room when a study is performed. Thus, the inflexible definition of direct supervision that has been proposed will not require the physician to act in any manner that will have any tangible effect on the quality of the studies completed.

Comments Regarding Specific Provisions
SVT believes that general supervision is the appropriate supervision level for all peripheral vascular ultrasound studies contained in the Extremity Arterial, Venous, and Arterial-Venous and Visceral and Penile Vascular Studies tables, including CPT codes 93922-93931 (noninvasive physiologic studies and duplex scans of extremity arteries), CPT codes 93965-93971 (noninvasive physiologic studies and duplex scans of extremity veins), CPT codes 93975-93981 (duplex scans of visceral and penile arteries and veins), and CPT code 93990 (duplex scan of hemodialysis access) are noninvasive procedures and are well within the capabilities of appropriately qualified nonphysicians to perform. Thus, in the Louisiana LMRP, direct supervision should be changed to general supervision for CPT codes 93875 - 93931, 93975 - 93979, and 93980 - 93981

Thank you, once again, for the opportunity to comment on this important policy.

Sincerely,

Patricia Marques, RN, RVT, FSVU
President, Society of Vascular Technology
Member, SVT Louisiana Carrier Medical Director Committee

Anne M. Jones, BSN, RN, RVT, RDMS, FSVU
Chair, SVT Government Relations Committee

Christy Cornwell, LPN RVT
Advisor, SVT Carrier Medical Director Network

William Harkrider, MD
Chair, SVT Louisiana Carrier Medical Director Committee

cc: SVT Board of Directors