California

Training Requirements:

The contractor itself does not credential providers. Medicare does expect a satisfactory level of competence from providers who submit claims for services rendered. Medicare services are only payable when performed by appropriate staff in an appropriate setting (explicitly stated in the Program Integrity Manual, Pub. 100-08, Chapter 13). Substandard studies are associated with unnecessary repetition of studies and overutilization of services. Substandard studies can directly endanger the patient if medical conditions are not able to be diagnosed because of a poorly or improperly conducted study, or, medical conditions are not recognized because the level of expertise of the interpreter does not meet accepted professional standards. The most commonly cited professional standard is that of the ACC/AHA (American College of Cardiology, American Hospital Association; www.acc.org/clinical/competence/echo). For transthoracic echo, Level 1 experience is defined as “not sufficient to perform or interpret echocardiograms independently,” Level 2 experience is a level appropriate for independent practice of echocardiograms, and Level 3 experience is appropriate for a center director.

The acceptable levels of competence are:

For the technical portion, an acceptable level of competence is fulfilled when the image acquisition is obtained under any one of the following conditions:

1. The service is performed personally by a physician with full training in cardiac structure and function, the acquisition of echocardiography images, echocardiographic equipment functions, and trouble shooting, e.g. similar to Level 2 experience of the ACC/AHA; or

2. The service is performed by a technician who is credentialed as either a Registered Diagnostic Cardiac Sonographer (RDCS) through the American Registry of Diagnostic Medical Sonographers or as a Registered Cardiac Sonographer (RCS) through the Cardiovascular Credentialing International; or

3. The service is performed at a laboratory (e.g. office, IDTF), credentialed by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL).

Note that the national supervision level is 1 (general supervision) for TTE and 3 (personal supervision) for the technical component of TEE. You may find the current year CMS RVU/fee schedule database (e.g. PPRRVU06.xls, column Z) at www.cms.hhs.gov.

For the professional portion (interpretation), an acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting one of the following requirements:

For Transthoracic Echocardiography (TTE) and/or Transesophageal Echocardiography (TEE):

1. The physician is ABIM board certified or board eligible in Cardiovascular Diseases; OR

2. The physician provides the interpretation in conjunction with a study that was performed at a laboratory that is accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) and that is subject to such laboratory’s quality assurance policies and procedures (the ICAEL website is www.intersocietal.org/icael/apply/standards.htm).

For Transthoracic Echocardiography (TTE):

1. The physician has Level II training in transthoracic echocardiography, as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography (www.acc.org/clinical/competence/echo). Level II training is the basic level for independent practice. OR

2. The equivalent of Level II training of the ACC/AHA. NHIC requires that this training must be obtained by working under a mentor who is fully qualified to teach and supervise, e.g. Level III training of the ACC/AHA. (“Training and competence” are not demonstrated by prior reimbursement for multiple procedures by Medicare prior to the implementation of this LCD). OR

3. The physician has staff privileges to interpret hospital transthoracic echocardiograms at a hospital that participates in the Medicare program. NHIC further requires that the physician must be authorized by the hospital to interpret any and all TTE examinations and not just those obtained by him or herself. The hospital Echocardiography Laboratory must be accredited by ICAEL.

For Transesophageal Echocardiography (TEE), professional competence is fulfilled when:

1. The physician has Level II training in transthoracic echocardiography, as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, OR

2. NBE (National Board of Echocardiography) certification in TEE, OR

3. The equivalent of Level II training in TTE, AND additional training specific to TEE which should include: 1) A letter or certificate from the training supervisor (training program director, echocardiography laboratory director, or equivalent) documenting performance and interpretation of 50 supervised TEE cases, OR

4. The physician has staff privileges to interpret hospital TEE at a hospital that participates in the Medicare program. NHIC further requires that the physician must be authorized by the hospital to interpret any and all TEE examinations and not just those obtained by him or herself. The hospital Echocardiography Laboratory must be accredited by ICAEL. OR

5. The provider performs cardiovascular anesthesiology with experience in TEE.

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