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 I experience is defined as "not
sufficient to perform or interpret echocardiograms independently,"
Level II experience is a level appropriate for independent
practice of echocardiograms, and Level III 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 II
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 I (general supervision)
for TTE and III (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.
