Can Diagnostic Ultrasound Be Useful In The Right Hands?

Ron Raducanu DPM FACFAS

My colleagues confound and confuse me at times. I was very fortunate that in my residency, I had significant exposure to the benefits of offering diagnostic ultrasound as a modality in my future practice. I learned (along with my attendings because this was "new" at the time), what to look for and how to make out all those shades of gray you see when evaluating an image on the screen. Luckily, we were also sending our images to a radiologist who was always open to have us call him and ask about the results, and teach us how to “see” what was there.

It was a wonderful learning experience and interestingly, we didn’t even approach the idea of doing ultrasound-guided injection at the time. This only came a little later.

Flash forward just a couple of years and for some reason, there is an explosion of negativity towards this important and beneficial modality. Everybody is arguing over the benefits of investing in an ultrasound machine as insurers are now more closely screening our colleagues who have an ultrasound machine and use it.

Of course, someone figured out that if you use an ultrasound device to guide an injection, you get paid more for the injection. Wouldn’t you know, suddenly everyone was talking about getting a unit in their office. Just as suddenly, insurance claim forms become congested with this new code for ultrasound guided injection for seemingly simple injections that podiatrists had done for generations without the benefit of this type of visualization.

I have been following this “controversy” for better than 10 years and it crops up over and over again when this discussion comes up with our colleagues on the Internet. What confounds me is that if skilled users use this modality properly, ultrasound is an incredibly powerful tool that can almost replace magnetic resonance imaging (MRI) in giving important information. Additionally, why would insurers balk at offering a cheaper test in the office in comparison to a several hundred-dollar (or more than a thousand-dollar) MRI? Well, it is the nature of the beast, isn’t it? Milk the cow until it is dry and then complain that it won’t produce for you anymore.

I think we can all agree that needing any type of modality to give an injection in the area of the plantar fascia is a little overkill, no? There are some valid reasons to use an ultrasound to guide an injection in the foot and ankle, but that is not one of them.

Ultimately, if a few people abuse a code and cannot really justify its use, we all truly suffer and I think that is the case with using the ultrasound to guide an injection. There are a few instances in which this is justified in my mind, but I don’t think that should be the primary goal in securing this modality in your office. If you count how many tendons you’d like to get a better look at and not have to send out for an MRI, I think that in and of itself would convince you to have another look at ultrasound.

The other big factor, of course, is finding someone to train you to be able to make use of ultrasound and identify what you need to identify. That may not be so easy. In order to really make use of the unit, you have to be confident in what you are doing, reviewing and ultimately documenting. The fear is that if you “miss” something or a radiologist confronts you in a legal situation, you may not have a leg to stand on. In this instance, it is not a matter of being afraid of an audit because one particular code is being abused by others. If you aren’t comfortable with the technology, call it what it is, but don’t lean on someone else’s abuse as a reason not to offer this service.

In a post I read somewhere, one of our colleagues asked if it is now required in residency to learn to use an ultrasound. I can pretty confidently say that most residents don’t even get to see an actual ultrasound unit in their residency at all. That is a crying shame. This particular colleague asked something to the effect whether residents learn that they now need to use an ultrasound to guide all their injections. Once again, I can pretty confidently say that, no, they don’t learn that. If some do, the only fault can be put on that attending who is teaching them this, and the hope that a new residency graduate can put two and two together and make good use of bad information.

Do we need an X-ray to evaluate a bunion unless we are considering surgical repair? I will leave question open as I don’t want to incur the wrath of those who feel they have to use every single modality they can the first time they see a patient just in case that patient never returns.

As we have all realized over the years, the gravy train eventually ends whether we are part of it or not. That doesn’t mean the tool we use to ride the train is obsolete or lacks an appropriate use. Diagnostic ultrasound is and will be a very powerful tool that can provide a lot of information if a skilled user utilizes the technology in the right situation. It may take a little while longer than some might think to pay off the ultrasound machine but how much are we now spending on digital radiograph units? How much do we get paid for three views of a foot? The cost to repayment ratio is higher, even if you are not performing those ultrasound guided injections at all.

The next trick is finding a recent graduate who is comfortable with the technology and ready to help you offer something “new” and useful in your practice.

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