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> August 11, 2008
>
> Kerry Weems, Acting Administrator
>
> Centers for Medicare and Medicaid Services
>
> Department of Health and Human Services
>
> Room 445-G
>
> Hubert H. Humphrey Building
>
> 200 Independence Avenue, S.W.
>
> Washington, D.C. 20201
>
> **Re: Medicare Program; Revisions to Payment Policies Under the
> Physician Fee Schedule and Other Revisions to Part B for CY 2009;
> \[CMS-1403-P\]**
>
> Dear Acting Administrator Weems:
>
> My associate and I are practicing sports medicine physicians in Avon,
> CT, specializing in non-surgical orthopedics and musculoskeletal
> medicine. I am writing specifically to comment on The Centers for
> Medicare and Medicaid Services' (CMS) proposed rule for physician
> payment for 2009 as it relates to the provision of in-office
> diagnostic ultrasound and x-ray services, in particular the section
> titled "Independent Diagnostic Testing Facilities."
>
> I am deeply concerned about the CMS proposal requiring my practice to
> enroll as an IDTF in order to continue providing x-ray and ultrasound
> services to our patients.
>
> X-ray imaging is a critical part of any sports medicine practice.
> Although we do not currently have x-ray in our office, we have been
> planning to add this service, inasmuch as [not]{.underline} having
> this service readily available compromises our ability to provide
> timely diagnosis and cost-effective care. Local x-ray facilities in
> our area cannot provide timely diagnostic x-ray services, not are they
> available outside of normal business hours. Performing timely on-site
> x-rays is crucial to the provision of musculoskeletal care, and
> barriers placed in the path of performing this traditional service
> would also substantially limit my ability to practice sports medicine
> to a commonly accepted standard of care. It would also increase my
> malpractice risk and liability burden.
>
> August 11, 2008
>
> Page 2
>
> We currently [do]{.underline} provide diagnostic musculoskeletal (MSK)
> ultrasound services in my office. Ultrasound is an integral part of
> our practice; we use it
>
> not only diagnostically, but also therapeutically as an imaging
> modality to guide needle placement for injections.
>
> MSK ultrasound is best utilized as a clinical tool in the hands of the
> provider who knows the detailed history and exam of the patient. By
> providing MSK ultrasound in my office, I am often able to avoid more
> expensive imaging (such as MRI and CT scans), and I can typically make
> a more expedient diagnosis. Without this tool, my patients would have
> to schedule a more advanced imaging study, then return to our office
> for a follow-up visit, which delays diagnosis, decreases the quality
> of care, and increases the cost. Furthermore, by performing this
> service in the office, I can immediately review the results of the
> study with the patient, and show the patient the actual pathological
> findings. This involves the patient in a more meaningful way in the
> care process, which increases compliance with treatment and patient
> satisfaction, thereby enhancing treatment outcomes.
>
> In addition, we use MSK ultrasound therapeutically to aid in accurate
> placement of injections. Injections performed "blindly" (without the
> benefit of image guidance) have been shown to be inaccurate in up to
> 50% of the time, even in experienced hands. Ensuring accurate delivery
> of therapeutic treatment increases the likelihood of successful
> outcome, ultimately leading to decreased costs. In addition, I---and
> many other sports medicine physicians---are using MSK ultrasound for
> novel treatments of chronic tendon injuries, including performing both
> percutaneous needle tenotomy and platelet-rich plasma injections,
> which have been highly successful and which can prevent more expensive
> traditional "open" surgeries.
>
> Regarding MSK ultrasound (unlike cardiovascular, abdominal, and fetal
> ultrasound), the vast majority of radiologists, and virtually none of
> the ultrasound technologists, are routinely trained in this modality.
> The result is that MSK ultrasound is difficult, if not impossible, to
> obtain in most areas. In fact, those of us (non-radiologists) who have
> been properly trained in MSK ultrasound actually have more formal
> training and experience in this modality than do radiologists.
>
> My partner and I currently have over 80 hours of accredited CME
> activity specifically in MSK U/S training---vastly more than what
> radiologist routinely receive, as noted above. Furthermore, competency
> standards for sports medicine physicians using MSK U/S are currently
> being developed by a collaborative committee represented by providers
> of MSK U/S.
>
> August 11, 2008
>
> Page 3
>
> Aside from the administrative and cost burdens of enrolling as an IDTF
> and hiring a supervising radiologist, there is the very real factor of
> not being able to find an adequately trained radiologist to supervise
> physicians (at least regarding MSK U/S). Finding a radiologist who is
> appropriately trained in this technology to provide supervision at the
> level required may be difficult or
>
> prohibitively expensive, given the scarcity of this particular
> resource in my community. It would also be redundant given my own
> training.
>
> Therefore I urge CMS to exempt X-ray and MSK ultrasound services from
> the proposed expansion of IDTF standards in the Final Medicare
> Physician Fee Schedule Rule for CY 2009.
>
> I greatly appreciate the opportunity to submit these comments. Please
> do not hesitate to contact me at portlandvsp@jockdoctors.com with
> questions, or if I can provide you with additional information.
>
> Sincerely,
>
> Paul D. Tortland, D.O., FAOASM
>
> *Fellow of the American Osteopathic Academy of Sports Medicine*
>
> *Assistant Clinical Professor of Medicine, University of Connecticut
> School of Medicine*
>
> *President, Connecticut Osteopathic Medical Society*