Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography
2013; Elsevier BV; Volume: 26; Issue: 6 Linguagem: Inglês
10.1016/j.echo.2013.04.001
ISSN1097-6795
AutoresKirk T. Spencer, Bruce J. Kimura, Claudia E. Korcarz, Patricia A. Pellikka, Peter S. Rahko, Robert J. Siegel,
Tópico(s)Cardiovascular Function and Risk Factors
ResumoAttention ASE Members:ASE has gone green! Visit www.aseuniversity.org to earn free continuing medical education credit through an online activity related to this article. Certificates are available for immediate access upon successful completion of the activity. Nonmembers will need to join ASE to access this great member benefit! ASE has gone green! Visit www.aseuniversity.org to earn free continuing medical education credit through an online activity related to this article. Certificates are available for immediate access upon successful completion of the activity. Nonmembers will need to join ASE to access this great member benefit! The value of ultrasound as a diagnostic cardiac modality is in many respects unparalleled. It is more portable and less expensive compared with other imaging modalities (computed tomography, magnetic resonance imaging, nuclear perfusion imaging). Unlike methods that expose patients to radiation, there are no known adverse effects of ultrasound used at diagnostic imaging intensities, which allows safe, serial evaluation of patients. Echocardiography permits rapid assessment of cardiac size, structure, function, and hemodynamics. Ultrasound images are evaluated in real time, which allows rapid diagnostic interpretation in a wide variety of settings, such as the outpatient clinic, inpatient ward, critical care unit, emergency department, operating room, remote clinic, and cardiac catheterization laboratory. Cardiac ultrasound is used across the entire spectrum of patient care from in utero to the frail elderly patient. Echocardiography is sensitive and specific for a broad range of clinical disorders, which allows evaluation of a wide variety of parameters with well-documented prognostic utility. In an effort to increase the value of echocardiography even further, platforms have been developed that incorporated advanced imaging capabilities (three-dimensional [3D], strain imaging) and complex algorithms for quantitative analysis. Equally important to the technical performance of this modality is the training of the clinicians who use it. Even before images are acquired, physicians who perform echocardiography need to be knowledgeable about the appropriate uses of the technique.1Douglas P.S. Garcia M.J. Haines D.E. Lai W.W. Manning W.J. Patel A.R. et al.ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography.J Am Soc Echocardiogr. 2011; 24: 229-267Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Accurate clinical use of cardiac ultrasound is completely dependent on users who are trained in image acquisition, analysis, and interpretation. Given the extensive expertise required for accurate use, guidelines have been established for the knowledge base, practical experience, and continued maintenance of competency for echocardiographic image acquisition.2Picard M.H. Adams D. Bierig S.M. Dent J.M. Douglas P.S. Gillam L.D. et al.American Society of Echocardiography Recommendations for Quality Echocardiography Laboratory Operations.J Am Soc Echocardiogr. 2011; 24: 1-10Abstract Full Text Full Text PDF PubMed Google Scholar, 3Bierig S.M. Ehler D. Knoll M.L. Waggoner A.D. American Society of Echocardiography minimum standards for the cardiac sonographer: a position paper.J Am Soc Echocardiogr. 2006; 19: 471-474Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 4Quinones M.A. Douglas P.S. Foster E. Gorcsan J. Lewis J.F. Pearlman A.S. et al.ACC/AHA clinical competence statement on echocardiography.J Am Soc Echocardiogr. 2003; 16: 379-402Abstract Full Text Full Text PDF PubMed Google Scholar Image analysis, interpretation, and reporting require extensive training. Recommendations for these also exist.2Picard M.H. Adams D. Bierig S.M. Dent J.M. Douglas P.S. Gillam L.D. et al.American Society of Echocardiography Recommendations for Quality Echocardiography Laboratory Operations.J Am Soc Echocardiogr. 2011; 24: 1-10Abstract Full Text Full Text PDF PubMed Google Scholar, 4Quinones M.A. Douglas P.S. Foster E. Gorcsan J. Lewis J.F. Pearlman A.S. et al.ACC/AHA clinical competence statement on echocardiography.J Am Soc Echocardiogr. 2003; 16: 379-402Abstract Full Text Full Text PDF PubMed Google Scholar, 5Gardin J.M. Adams D.B. Douglas P.S. Feigenbaum H. Forst D.H. Fraser A.G. et al.Recommendations for a standardized report for adult transthoracic echocardiography: a report from the American Society of Echocardiography's Nomenclature and Standards Committee and Task Force for a Standardized Echocardiography Report.J Am Soc Echocardiogr. 2002; 15: 275-290Abstract Full Text Full Text PDF PubMed Google Scholar In addition, there are comprehensive guidelines that incorporate extensive recommendations for echocardiographic use in clinical practice.6Mor-Avi V. Lang R.M. Badano L.P. Belohlavek M. Cardim N.M. Derumeaux G. et al.Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE Consensus Statement on Methodology and Indications.J Am Soc Echocardiogr. 2011; 24: 277-313Abstract Full Text Full Text PDF PubMed Google Scholar, 7Rudski L.G. Lai W.W. Afilalo J. Hua L.Q. Handschumacher M.D. Chandrasekaran K. et al.Guidelines for the echocardiographic assessment of the right heart in adults.J Am Soc Echocardiogr. 2010; 23: 685-713Abstract Full Text Full Text PDF PubMed Google Scholar, 8Zoghbi W.A. Chambers J.B. Dumesnil J.G. Foster E. Gottdiener J.S. Grayburn P.A. et al.Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound.J Am Soc Echocardiogr. 2009; 22: 975-1014Abstract Full Text Full Text PDF PubMed Google Scholar, 9Nagueh S.F. Appleton C.P. Gillebert T.C. Marino P.N. Oh J.K. Smiseth O.A. et al.Recommendations for the evaluation of left ventricular diastolic function by echocardiography.J Am Soc Echocardiogr. 2009; 22: 107-133Abstract Full Text Full Text PDF PubMed Google Scholar, 10Baumgartner H. Hung J. Bermejo J. Chambers J.B. Evangelista A. Griffin B.P. et al.Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice.J Am Soc Echocardiogr. 2009; 22 (quiz 101-2; erratum 442): 1-21Abstract Full Text Full Text PDF PubMed Google Scholar, 11Lang R.M. Bierig M. Devereux R.B. Flachskampf F.A. Foster E. Pellikka P.A. et al.Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group.J Am Soc Echocardiogr. 2005; 18: 1440-1463Abstract Full Text Full Text PDF PubMed Google Scholar, 12Zoghbi W.A. Enriquez-Sarano M. Foster E. Grayburn P.A. Kraft C.D. Levine R.A. et al.Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.J Am Soc Echocardiogr. 2003; 16: 777-802Abstract Full Text Full Text PDF PubMed Google Scholar The expertise required to use advanced platforms and the extensive training required to appropriately analyze and interpret transthoracic images have traditionally only been fulfilled by specialists in cardiovascular medicine. Two major developments have changed the practice of cardiac ultrasound:•Development of small ultrasound platforms. These devices have significantly fewer features and capabilities, which make them easier to operate. Despite their small size, they have proven diagnostic utility when used by physicians with comprehensive echocardiographic training.13Cardim N. Golfin C.F. Ferreira D. Aubele A. Toste J. Cobos M.A. et al.Usefulness of a new miniaturized echocardiographic system in outpatient cardiology consultations as an extension of physical examination.J Am Soc Echocardiogr. 2011; 24: 117-124Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 14Egan M. Ionescu A. The pocket echocardiograph: a useful new tool?.Eur J Echocardiogr. 2008; 9: 721-725Crossref PubMed Scopus (0) Google Scholar, 15Frederiksen C.A. Juhl-Olsen P. Larsen U.T. Nielsen D.G. Eika B. Sloth E. New pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners.Acta Anaesthesiol Scand. 2010; 54: 1217-1223Crossref PubMed Scopus (0) Google Scholar, 16Giusca S. Jurcut R. Ticulescu R. Dumitru D. Vladaia A. Savu O. et al.Accuracy of handheld echocardiography for bedside diagnostic evaluation in a tertiary cardiology center: comparison with standard echocardiography.Echocardiography. 2011; 28: 136-141Crossref PubMed Google Scholar, 17Kimura B.J. Gilcrease G.W. Showalter B.K. Phan J.N. Wolfson T. Diagnostic performance of a pocket-sized ultrasound device for quick-look cardiac imaging.Am J Emerg Med. 2012; 30: 32-36Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 18Liebo M.J. Israel R.L. Lillie E.O. Smith M.R. Rubenson D.S. Topol E.J. Is pocket mobile echocardiography the next-generation stethoscope? A cross-sectional comparison of rapidly acquired images with standard transthoracic echocardiography.Ann Intern Med. 2011; 155: 33-38Crossref PubMed Google Scholar, 19Prinz C. Voigt J.U. Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography.J Am Soc Echocardiogr. 2011; 24: 111-116Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 20Reant P. Dijos M. Arsac F. Mignot A. Cadenaule F. Aumiaux A. et al.Validation of a new bedside echoscopic heart examination resulting in an improvement in echo-lab workflow.Arch Cardiovasc Dis. 2011; 104: 171-177Crossref PubMed Scopus (0) Google Scholar Simplified operation and substantially smaller size and cost have opened their potential use to nontraditional cardiac ultrasound users. However, the easier operation of small devices does not obviate the need for training to acquire and interpret cardiac images.•Physicians from diverse specialties have become interested in having access to the diagnostic value of cardiac ultrasound in clinical settings relevant to their scope of practice. This has led to the concept of focused use of cardiac ultrasound. The hypothesis is that nontraditional users, who have less training in cardiac image acquisition and interpretation compared with those trained in echocardiography, can learn to acquire and interpret cardiac ultrasound images as an adjunct to their physical examination assessment. It is important to maintain excellence in the practice of echocardiography, a discipline that requires significant training and knowledge of guidelines for acquisition, analysis, and interpretation, while enabling ultrasound to be used as a tool by nonechocardiographers to augment their clinical assessments traditionally based on physical examination alone. It is recognized that there is a broad continuum of imaging and interpretive expertise among physicians with cardiac ultrasound training. Some users may understand more advanced imaging acquisition, analysis, and interpretation. However, as in most areas of medicine, specific thresholds of expertise need to be defined. This is critical to providing excellent patient care by holding physicians accountable to practice within their scope of expertise as well as setting expectations for the practitioner, referring physician, and patient. The current document distinguishes the emerging field of focused cardiac ultrasound (FCU) as a bedside adjunct to the physical examination and echocardiography. Defining the distinctions between these techniques will allow practitioners to realize the utility of FCU and yet maintain the value of echocardiography. This guideline will not address ultrasound imaging outside of the cardiovascular system or nontransthoracic ultrasound modalities (ie, transesophageal echocardiography). This guideline is specific to cardiac imaging in the adult. FCU is a focused examination of the cardiovascular system performed by a physician by using ultrasound as an adjunct to the physical examination to recognize specific ultrasonic signs that represent a narrow list of potential diagnoses in specific clinical settings. There are a variety of terms that have been used to describe a focused ultrasound of the heart. The importance of defining the nomenclature is the recognition that these procedures are distinct from the practice of echocardiography, as outlined in section 3. The American Society of Echocardiography (ASE) recommends the use of the term “focused cardiac ultrasound,” but recognizes that other terms are in use (Table 1). The literature also contains hybrid terms that should be avoided because the expectations of the examination, equipment used, expertise in image acquisition, and proficiency in data analysis and interpretation are unclear if these terms are used. Such terms include “focused echocardiography,” “hand-held echocardiography,” “hand-carried echocardiography,” “point of care echocardiography,” and “directed echocardiography.” The appropriate terminology for echocardiography has previously been established and includes “complete” or “comprehensive” echocardiography and “limited” echocardiography.Table 1Terms in use that may refer to FCUHand-held cardiac ultrasoundPoint-of-care cardiac ultrasoundUltrasound stethoscopeHand-carried cardiac ultrasoundBedside cardiac ultrasoundQuick look cardiac ultrasound Open table in a new tab The technical requirements for equipment, expertise for image acquisition, and the knowledge base for image analysis and interpretation have been well defined for echocardiography. This permits the appropriate and safe use of echocardiography in an unlimited number of clinical scenarios and permits its users to have a very broad scope of practice. Because of equipment capability, image acquisition training, image interpretation training, and image interpretation knowledge base, the practitioner of FCU will have a scope of practice that is restricted to the equipment and skill set that he or she possesses. The scope of practice may be a specific patient population or a clinical setting. The specific clinical question to be addressed and the cardiac abnormalities that can be ruled in or out with the focused examination will be narrow. The difference between the limited echocardiogram and FCU rests in the expectations of the examination, the equipment used, the expertise in image acquisition, and proficiency in data analysis and interpretation. “Limited” refers to a reduced number of images, whereas “focused” refers to a narrowed, specific question and scope of expertise (Tables 2 and 3).Table 2Differences between limited echocardiography and FCULimited echocardiography Definitive examination that requires knowledge and expertise described below Knowledge that specific additional images would be useful Expertise to acquire additional images from all acoustic windows Knowledge that a specific additional ultrasound technique would be useful Expertise to acquire additional images with all cardiac ultrasound imaging modalities Knowledge to identify all expected normal structures and/or artifacts from all views Knowledge to identify pathologic findings on structure of clinical interest Knowledge to look for and identify lesions associated with other findings, whether in the same view of other parts of the study Knowledge to identify incidental findings within images acquired Knowledge of quantitative techniques Expertise to apply quantitative techniques Expertise to answer any referral question with appropriate negative and positive pertinent findingsFCU Identify the presence or absence of one or several specific findings by using a defined, preestablished image acquisition protocol Open table in a new tab Table 3Differences between limited echocardiography and FCULimited echocardiogramFCUPatientsAny adult patientDefined scope of practiceLocation of imagingAny locationDefined scope of practiceImage protocolSkill to perform any view, but only selected views may be requiredLimited number of viewsEquipmentFull function (M-mode, 2D, color Doppler, spectral Doppler, TDI, contrast), EKG gated2D minimumTransducersMultipleSingleMeasurementsAdvanced quantificationNone or linear measurementAcquisitionSonographer or level II/III echocardiographerPhysician with FCU trainingInterpretationEchocardiographer; all pathology and normal structures within imaging viewPhysician with FCU training defined, limited scopeImage storageDICOM format, archived for easy retrieval and reviewOnly for select indications (see text)DocumentationFormal report meeting ICAEL standardsDocumentation as brief report or as part of PE depending on indicationBilling93308NoneTDI, Tissue Doppler imaging; ICAEL, Intersocietal Commission for the Accreditation of Echocardiography Laboratories; PE, physical examination. Open table in a new tab TDI, Tissue Doppler imaging; ICAEL, Intersocietal Commission for the Accreditation of Echocardiography Laboratories; PE, physical examination. With FCU, subjective interpretation of one or a few prechosen targets of interest is emphasized, with the intent that subsequent referral for an echocardiographic study will delineate and measure all findings, including incidental or associated findings, which may go unrecognized by FCU. Abnormalities when using FCU are typically classified as present or absent by using a predefined specific imaging protocol. The practitioner is “focused” on making a specific diagnosis or identifying a potentially significant valvular, hemodynamic, or structural abnormality. This approach allows rapid detection of a small number of evidence-based targets at the bedside that could provide clues to the patient's cardiac status and requires less training and expertise than that considered adequate to perform echocardiography. The results of an FCU examination can be used in conjunction with other bedside measures, such as the physical examination, in formulating an initial diagnostic impression and guiding appropriate early triage and management. Although a FCU evaluation may facilitate initial management, all patients with abnormal findings not previously documented on echocardiography should be referred for a comprehensive echocardiographic examination. A physician with only FCU expertise does not have the image acquisition or interpretation expertise to completely evaluate a symptomatic cardiac patient. Comprehensive echocardiography allows additional characterization of an abnormality from supplementary views, complete assessment of the hemodynamics associated with a lesion and further evaluation of a finding with additional ultrasound tools (Doppler, 3D, etc). When FCU evaluation fails to detect any prespecified abnormalities in a patient with symptoms or signs of cardiovascular disease, referral for comprehensive echocardiography is probably warranted. For example, in a patient with dyspnea, although FCU may allow rapid and accurate exclusion of a large pericardial effusion or significant left ventricle (LV) systolic dysfunction, numerous other cardiac pathologies missed by FCU, but detectable by comprehensive echocardiography, remain to be investigated as alternative causes of the patient's breathlessness. The implications of the FCU examination go beyond its terminology in regard to the perception of the act by the patients, their families, health care professionals, and the legal profession. Patients who undergo or witness an FCU examination should be informed that this particular use of ultrasound is a new method that is meant to enhance bedside examination by providing “early” or “preliminary” information that is used to formulate the physician's initial impression. Importantly, it is not equivalent to a diagnostic echocardiographic study. The operator is incorporating his or her recognition and knowledge of specific findings within the scope of his or her clinical practice in the care of the patient. Patients and their families should be told that significant abnormal findings will be confirmed with a complete diagnostic echocardiogram. Patients should understand that an echocardiogram will be performed as soon as practical if their symptoms or signs warrant one. Likewise, when patients undergo echocardiography after an FCU examination, they should understand that this is not a duplicate or repeated examination but a comprehensive evaluation of their condition by an expert in cardiac imaging. With echocardiography, the whole sum of knowledge is applied “upfront,” with measurements of normal structures and function, documentation of findings other than those that may have prompted the referral, and a thorough search to answer the referral question. The ASE has provided detailed recommendations for the performance, interpretation, documentation, and image storage that apply to comprehensive and limited echocardiographic examinations.2Picard M.H. Adams D. Bierig S.M. Dent J.M. Douglas P.S. Gillam L.D. et al.American Society of Echocardiography Recommendations for Quality Echocardiography Laboratory Operations.J Am Soc Echocardiogr. 2011; 24: 1-10Abstract Full Text Full Text PDF PubMed Google Scholar These standards were developed to contribute to patient and provider satisfaction, and to improve patient outcomes. The “limited” descriptor of a limited echocardiogram simply refers to the fact that, compared with a comprehensive examination, the number of views obtained and the number of images that are acquired are fewer. Every other aspect of limited echocardiography is the same as for comprehensive echocardiography. The practitioner will completely interpret all available data from all images, albeit in a limited echocardiogram from a more “limited” number of images. The clinical decision to perform a limited echocardiogram, as opposed to a comprehensive examination, requires expertise in echocardiography and specific knowledge of the appropriate indications. When performing a limited echocardiogram, the imager must have the knowledge of all views necessary to characterize or exclude the referral diagnosis. In addition, a clinician performing a limited echocardiogram must be cognizant of the potential to miss findings not in the field of view that (1) could offer an alternative explanation for the patient's referral or (2) are incidental but clinically significant. A limited echocardiogram is more often used as a follow-up examination, after a prior comprehensive echocardiogram has delineated all findings. When performing limited echocardiography, report generation and comparison with prior studies must follow standard requirements of echocardiography. Ultrasound machines have evolved from large, poorly moveable devices to hand-carried ultrasound instruments and now pocket-sized devices. It is not the size or weight characteristics that define an echocardiographic machine. The use of FCU in this document generally applies to a nonechocardiographer imager who is using a basic ultrasound device. However, nonechocardiographer users who acquire images with a high-end platform or users trained in echocardiography who use pocket ultrasound devices are also performing FCU (Table 4).Table 4Types of cardiac ultrasound examinations by level of training and nature of equipmentEquipment capabilitiesTraining levelNonechocardiographerEchocardiographerBasicFCUeFCUComprehensiveFCUEchocardiography Open table in a new tab The equipment used for limited echocardiography should be capable of performing two-dimensional (2D) echocardiography, M-mode, color-flow imaging, and spectral and tissue Doppler ultrasound. Although all of these modalities may not be used in every case, their availability is critical in preserving the expectation that a patient referred for echocardiography (whether limited or complete) will receive the examination needed to delineate all abnormalities. Platforms for FCU are intended to answer a specific clinical question within the technologic limitations of a small device and thus do not require all these modalities. Echocardiographic examinations (comprehensive and limited) require that a broad selection of transducers be available for use, whereas FCU does not. In the process of miniaturization, many of the fundamental capabilities of an echocardiogram have been omitted, including advanced signal processing and electrocardiographic (EKG) gating. The small screen size and reduced image resolution on devices used in FCU may limit recognition of diagnostic findings. The platform of a typical FCU device is incompatible with the performance of detailed or gated measurements that are the minimum professional standard for echocardiography. Echocardiographic platforms must store images in a method compatible with DICOM (Digital Imaging and Communications in Medicine) standards. Platforms that do not export in the DICOM format should not be used to perform echocardiography (limited or comprehensive). Differentiating the image acquisition aspects of FCU and “Limited TTE” is best made by noting the requirements for image acquisition for limited echocardiography. Guidelines for specific training and credentialing of sonographers and physicians to acquire images in echocardiography have been published.2Picard M.H. Adams D. Bierig S.M. Dent J.M. Douglas P.S. Gillam L.D. et al.American Society of Echocardiography Recommendations for Quality Echocardiography Laboratory Operations.J Am Soc Echocardiogr. 2011; 24: 1-10Abstract Full Text Full Text PDF PubMed Google Scholar, 4Quinones M.A. Douglas P.S. Foster E. Gorcsan J. Lewis J.F. Pearlman A.S. et al.ACC/AHA clinical competence statement on echocardiography.J Am Soc Echocardiogr. 2003; 16: 379-402Abstract Full Text Full Text PDF PubMed Google Scholar, 21Ehler D. Carney D.K. Dempsey A.L. Rigling R. Kraft C. Witt S.A. et al.Guidelines for cardiac sonographer education: recommendations of the American Society of Echocardiography Sonograpber Training and Education Committee.J Am Soc Echocardiogr. 2001; 14: 77-84Abstract Full Text PDF PubMed Google Scholar Specific imaging components for completion of a comprehensive examination are specified. Practitioners who perform limited echocardiography need familiarity with all the windows and views of a comprehensive examination, because different clinical situations may require a particular subset of a comprehensive examination. Limited echocardiographic examinations may require any or all of the modalities used in a comprehensive examination. Practitioners who perform limited echocardiography need to be proficient in 2D, pulsed-wave and continuous-wave Doppler, color-Doppler, tissue Doppler, and M-mode echocardiography. The limited echocardiographic acquisition skill set must include familiarity with all transducers used in comprehensive echocardiography, because the clinical question, which may be answered with a limited echocardiogram examination, may require any of a number of transducers. Image quality of a limited echocardiographic examination is expected to be equal to comprehensive echocardiography to provide comparable data for side-by-side comparisons during assessment of temporal changes in patient status. In the practice of limited echocardiography, the user is responsible for interpretation and delineation of primary, associated, and “incidental” findings that are apparent or became apparent while obtaining the views. Similar to the radiographic standard of chest X-ray interpretation in which the radiologist is accountable for the diagnosis of a solitary pulmonary nodule even when the primary cardiac finding of the radiograph is cardiomegaly, a limited echocardiogram that “excludes” a pericardial effusion is still accountable for a diagnosis of any evident wall-motion abnormality, valvular disease, or significant finding clearly present in the specific views recorded. Moreover, the interpretation must include assessment of key structures and cardiac function, including performance of measurements when feasible. Finally, there must be a report that includes key elements of cardiac structure and function, findings, and interpretation. In these circumstances, an echocardiogram, comprehensive or limited, provides the maximum ultrasonic diagnostic capabilities and expert interpretation and upholds the perceived standards and justified costs of the echocardiogram held by the referring physician, patient, and payers. FCU does not require quantitation or provide equivalent diagnostic capability, and it is not the expectation of the user to delineate and quantify all findings viewed. In the United States, the Center for Medicare Service's Current Procedural Terminology (CPT) codes provides a system in which a participating health care provider can bill for the particular services rendered. The calculated reimbursement for a procedure is determined on a “relative value” scale that takes into account practice expense, physician work, malpractice costs, and the relative value of the procedure adjusted to regional factors where the service was rendered, the so-called resource-based relative value scale. In calculating the physician work component for limited echocardiography, the following factors are considered: physician time, technical skill, physical effort, mental effort, judgment, and stress due to potential risk to the patient. The submission of limited echocardiographic CPT (93308) for FCU would be inappropriate because the components used in the resource-based relative value scale cost estimates for FCU and limited echocardiography are different. Practice expenses are different primarily due to the substantial differences in machine, room, documentation, image storage, and personnel costs. Liability is different because the echocardiographer is responsible for interpretation and delineation of primary, associated
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