have tired of treating my ultrasound exam of a patient as separate from my physical exam. In the emergency department and ICU where I practice, ultrasound is much more than an adjunct, it is an integral part of my evaluation of the patient.
The JAMA series on Rational Clinical Examination has taught us that each physical exam maneuver needs to be evaluated with an evidenced-based assessment, that includes sensitivity and specificity. We have learned through the series that many specific exams are near worthless, while others provide some value though far less than we may have been led to believe during our medical school and residency training.
The knowledge of the fall failings of the traditional physical exam, and the near universal availability of bedside ultrasound has changed the physical exam fundamentally and forever. Many previous exam maneuvers such as palpating ventricular heave or PMI, are distant markers of what you fundamentally care about which is cardiac function. With ultrasound that gives you direct visualization of structures, ventricular function can be directly interpreted even by novice registrars.
A stethoscope, reflex hammer, or pen light are tools that aid my physical exam. Ultrasound is just another tool, that quickly an easily lets me answer questions during my physical. There is nothing that feeling for abdominal bruits can tell me that cannot be more quickly and more definitively answered with an abdominal probe in your hand.
In the United States, Medicare billing requires a certain number of physical exam bullets fore a specific level of billing which prompts physicians to continue performing useless physical exam maneuvers on patients, or even worse document that they performed them without actually doing so. While unethical, this grows out of a frustration with documentation requirements that do not fit with our current knowledge and practice of medicine. it is also unethical for Medicare to subject the patient to fruitless parts of the physical without any benefit to their care.
The other billing issue is the requirements for billing for the ultrasound. Per CMS, the following three components are necessary.
- Interpretation – a written interpretation and report must be completed and be maintained in the patient’s medical record. The report must describe the structures or organs studied and supply an interpretation of the findings.
- Medical necessity – the medical record documentation must indicate why the test was medically necessary.
- Image Retention – appropriate image(s) with measurements when clinically indicated of the relevant anatomy / pathology must be permanently stored and available for future review. Please note that an image is now required for all procedures performed with an ultrasound.
It is my opinion, these requirements are met with this new format.
What I have become a strong advocate for, is incorporating my ultrasound findings directly into my physical exam documentation. Assessments made by ultrasound should be viewed as tests answering questions, and should documented accordingly.
Below I shown an example comprehensive physical exam of a patient presenting with shortness of breath, who has decompensated heart failure. I have highlighted the items included based on ultrasound.
Vital Signs: BP 128/68 | Pulse 111 | Temp 37.7 °C (Oral) | Resp 24 | Wt 118.8 kg | SpO2 89% on room air.
Constitutional: Mild respiratory distress. Does not appear toxic.
Eyes: White and quiet. PERRL (R 3~2 | 3~2 L).
ENMT: Moist oral mucosa. No tonsillar exudates or hypertrophy. No swelling or erythema of posterior oropharynx.
Respiratory: Increased effort. Rales bilaterally. Sliding lung signs present bilaterally. Approximately 12 B-lines bilaterally. No significant pleural effusion.
Cardiovascular: Regular tachycardic rhythm. Soft S3 heard with no murmur. No pericardial effusion. Dilated cardiac structure. Moderately decreased cardiac function. Proximal thoracic aorta 20mm. No significant aortic valve or mitral valve stenosis. E-point septal separation is 12mm.
Gastrointestinal: Soft. No tenderness to palpation. No intraperitoneal free fluid. Maximum abdominal aorta diameter 2.9 cm. IVC diameter 2.4cm with no respiratory variation. Bladder decompressed with Foley catheter balloon in place.
Genitourinary: Foley catheter in place.
Neurologic: No deficits of cranial nerves. Strength and sensation normal in bilateral upper and lower extremities.
Musculoskeletal: Moving all extremities freely. No swelling or erythema of legs. Normal graded compression of bilateral common femoral vein and popliteal vein.
Skin: Warm and dry. No rashes or mottling.
Psychiatric: Fully oriented. Anxious but interacting appropriately for situation.
I would be glad to hear your feedback. Contact me if your are interest in joining me in my lobbying efforts of ACEP, ABIM, and most importantly CMS.