United States Government Accountability Office

GAO Report to Congressional Committees

MEDICARE 

ULTRASOUND 

PROCEDURES 

Consideration of 

Payment Reforms and 

Technician 

Qualification 

Requirements 

June 2007 

 

GAO-07-734 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

June 2007

MEDICARE ULTRASOUND PROCEDURES

Consideration of Payment Reforms and 

Highlights of GAO-07-734, a report to Technician Qualification Requirements 

congressional committees 

Medicare spending on imaging 

services, among which are 

ultrasound procedures that use 

sound waves to facilitate diagnosis, 

nearly doubled from 1999 to 2004. 

The Congress required GAO to 

examine Medicare’s payment 

methods for ultrasound procedures 

and whether the technicians that

conduct them—called

sonographers—should be subject 

to qualification standards, such as

having to undergo a certification 

process called credentialing. This 

report addresses (1) the ultrasound

procedures commonly used to 

diagnose medical conditions of

Medicare beneficiaries, particularly

for beneficiaries in a skilled 

nursing facility (SNF), (2) the

financial impact of changing how

Medicare pays for ultrasound 

exams and associated equipment 

and ambulance transportation for 

beneficiaries in a SNF, and 

(3) the factors for the Centers for

Medicare & Medicaid Services 

(CMS) to consider in determining

whether to establish credentialing 

or other requirements for

sonographers. For this review,

GAO analyzed Medicare claims 

data and conducted interviews and 

literature reviews. 

What GAO Recommends

CMS should require sonographers

providing Medicare-covered 

ultrasound exams to either be 

credentialed or work in an

accredited facility. CMS stated that 

it would consider this 

recommendation. 

Three-fourths of the approximately 41 million ultrasound procedures 

provided to Medicare beneficiaries in 2005 in any setting were one of two 

types: (1) echocardiograms to diagnose heart conditions or (2) noninvasive 

vascular procedures used to monitor blood flow and detect blockage or 

injury in veins and arteries. Ultrasound procedures consist of the ultrasound 

exam itself and the physician’s interpretation of the exam. Nearly all of the 

ultrasound exams provided under Medicare Part B, which covers physician, 

hospital outpatient, diagnostic testing, and certain other services, were 

performed in physicians’ offices and hospital outpatient departments. Of 

these exams, less than 1 percent were conducted in SNFs or homes, 

generally using ultrasound equipment that was transported to these settings 

by a mobile provider. Among beneficiaries in SNF stays not covered by 

Medicare who received ultrasound exams in SNFs, noninvasive vascular 

exams were the most prevalent type performed. 

Two ultrasound procedure payment changes affecting SNF beneficiaries that 

GAO examined would likely increase expenditures and beneficiary cost 

sharing. If CMS had paid to transport ultrasound equipment to beneficiaries 

in SNF stays not covered by Medicare, which is not currently done, Medicare 

expenditures could have increased by an estimated $9.8 million and 

beneficiary cost sharing could have been about $2.6 million higher in 2005,

assuming the number and location of services would not change in response 

to this policy. Moreover, paying separately for ultrasound exams and related 

transportation during beneficiaries’ Medicare-covered SNF stays, as opposed 

to bundling these and other services into a single daily payment as CMS 

currently does, could have increased Medicare payments by about $22.0 

million and beneficiary cost sharing by about $13.4 million in 2005, assuming 

no change in service use due to the revised policy. The actual financial 

impact for Medicare could differ from these estimates if, for example, 

providers increased their service provision due to these policy changes. 

Factors for CMS to consider in determining whether to establish 

credentialing or other qualification requirements for sonographers include 

the evidence of the value of setting such requirements and variation in 

federal requirements for sonographers. The skill of the sonographer 

conducting an ultrasound is critical for its use to support a physician’s 

correct diagnosis; poorly captured images can lead to misdiagnoses or 

unnecessarily repeated exams. Findings from several peer-reviewed studies, 

the Medicare Payment Advisory Commission, and ultrasound-related 

professional organizations support requiring that sonographers either have 

credentials or operate in facilities that are accredited, where specific quality 

standards apply. In some localities and practice settings, CMS or its 

contractors have required that sonographers either be credentialed or work 

in an accredited facility. Medicare’s inconsistent requirements undermine 

assurance that beneficiaries are receiving high-quality services across the 

country. 

www.gao.gov/cgi-bin/getrpt?GAO-07-734.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact A. Bruce 

Steinwald at (202) 512-7114 or 

steinwalda@gao.gov. 
Contents 

Letter 1

Results in Brief 5

Background 7

The Most Common Medicare Ultrasound Procedures in 2005 Were 

Echocardiograms and Noninvasive Vascular Studies 13 

Changing Ultrasound Payment Methods Would Likely Increase 

Expenditures and Beneficiary Cost Sharing 19 

Evidence and Variation in Federal Requirements Are Among 

Factors to Consider in Determining Whether to Establish 

Credentialing or Other Qualification Requirements for 

Sonographers 26

Conclusions 36

Recommendation for Executive Action 37 

Agency Comments and Our Evaluation 37 

Appendix I Scope and Methodology 39 

Appendix II Ultrasound Procedures and Medicare Part B 

Payments in 2005 49 

Appendix III Detailed Estimates of the Financial Impact of 

Changing Medicare Ultrasound Payment Methods 55 

Appendix IV Studies on Accreditation of Facilities and the 

Credentialing of Sonographers 57 

Appendix V Information about Groups That Support Ultrasound 

Credentialing and Accreditation Requirements 59 

Appendix VI Comments from the Centers for Medicare & 

Medicaid Services 61 

Page i GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix VII GAO Contact and Staff Acknowledgments 65 

Tables 

Table 1: Medicare Payment Methodology for Selected Imaging

Procedures and Associated Transportation for 

Beneficiaries in SNF Stays 11 

Table 2: Financial Impact of Part B Ultrasound Equipment 

Transportation Payments, 2005 20 

Table 3: Increase in Part B Expenditures and Beneficiary Cost

Sharing Due to Separate Payments for Ultrasound Services 

during Part A-Covered SNF Stays, 2005 24 

Table 4: Number of Ultrasound Procedures Provided to Medicare 

Beneficiaries by Site of Service and Level of Physician 

Supervision Required, 2005 49 

Table 5: Top Five Medical Conditions Diagnosed by Type of

Ultrasound Procedure Provided to Medicare Beneficiaries 

under Medicare Part B, 2005 51 

Table 6: Top Five Medical Conditions Diagnosed by Type of

Ultrasound Procedure Provided in SNFs to Medicare 

Beneficiaries in Noncovered SNF stays and Paid Under 

Medicare Part B, 2005 53 

Table 7: Financial Impact of Ultrasound Equipment Transportation 

Payments, 2005 55 

Table 8: Percentage Change in Number of Ultrasound Exams in 

SNFs, 1995 to 1997 56 

Figures 

Figure 1: Percentages of Total Procedures and Total Part B 

Medicare Payments for Ultrasound Procedures Provided 

to Beneficiaries, 2005 14 

Figure 2: Percentages of Total Procedures and Total Part B 

Medicare Payments for Ultrasound Procedures 

Conducted in SNFs for Beneficiaries in Noncovered SNF 

Stays, 2005 17 

Figure 3: Medicare Carriers’ Part B LCDs on Noninvasive Vascular 

Diagnostic Ultrasound Procedures, as of April 2007 32 

Page ii GAO-07-734 Medicare Diagnostic Ultrasound Services
Abbreviations 

AIUM American Institute of Ultrasound in Medicine 

ARDMS American Registry for Diagnostic Medical Sonography 

BBA Balanced Budget Act of 1997 

BETOS Berenson-Eggers Type of Service 

CCI Cardiovascular Credentialing International 

CMS Centers for Medicare & Medicaid Services 

CoP Medicare Conditions of Participation

CPT Current Procedural Terminology 

FDA Food and Drug Administration 

HCPCS Healthcare Common Procedure Coding System 

HHS Department of Health and Human Services 

ICAVL Intersocietal Commission for the Accreditation of Vascular 

 Laboratories 

IDTF independent diagnostic testing facility 

LCD Local Coverage Determination 

MedPAC Medicare Payment Advisory Commission 

NCD National Coverage Determination 

NCH National Claims History

OIG Office of Inspector General 

PPS prospective payment system 

SAF Standard Analytical File

SNF skilled nursing facility 

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Page iii GAO-07-734 Medicare Diagnostic Ultrasound Services
United States Government Accountability Office

Washington, DC 20548 

June 28, 2007 

The Honorable Max Baucus 

Chairman 

The Honorable Charles Grassley 

Ranking Minority Member 

Committee on Finance 

United States Senate 

The Honorable John D. Dingell 

Chairman 

The Honorable Joe Barton 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

The Honorable Charles B. Rangel 

Chairman 

The Honorable Jim McCrery 

Ranking Minority Member 

Committee on Ways and Means 

House of Representatives 

Medicare spending on imaging services nearly doubled from $5.7 billion in

1999 to $10.9 billion in 2004, in part due to growth in the number of 

procedures.1 Diagnostic ultrasound procedures, an imaging service which 

uses high-frequency sound waves to create images of internal body organs

and blood flow, accounted for about one-fourth of this spending in 2004.2

Growth in the use of diagnostic ultrasound procedures has been due in 

part to technological advances, which have improved the quality of 

ultrasound images and physicians’ ability to employ them to diagnose 

 1

See Medicare Payment Advisory Commission (MedPAC), A Data Book: Healthcare 

Spending and the Medicare Program, June 2006. MedPAC is an independent federal body 

established by law to advise the Congress on issues affecting the Medicare program,

including its payment methods. MedPAC’s data cited here are based on Medicare Part B

payments under the physician fee schedule and include beneficiary cost sharing. Medicare

Part B covers physician services, hospital outpatient services, diagnostic tests, and 

ambulance services as well as certain other services such as physical therapy. 

2

See MedPAC 2006. 

Page 1 GAO-07-734 Medicare Diagnostic Ultrasound Services
medical conditions. Technological advances also have led to the 

development of ultrasound devices that are smaller and more portable. 

The enhanced portability of ultrasound equipment has made it easier for 

beneficiaries to receive ultrasound exams in skilled nursing facilities 

(SNF) or beneficiaries’ homes to which ultrasound equipment generally

must be transported by a mobile provider. 

Ultrasound procedures consist of two parts—the ultrasound exam itself 

and the physician’s interpretation of the exam. The first part of the 

procedure—the ultrasound exam—generally involves an ultrasound 

technician called a sonographer taking the image. The second part of the 

procedure is the physician’s interpretation of images from the ultrasound 

exam.3

 Medicare, administered by the Centers for Medicare & Medicaid 

Services (CMS), pays for the ultrasound exam and the physician’s 

interpretation of it separately or together.4

Medicare covers ultrasound and other imaging procedures and certain 

related transportation under Part A and Part B of the program, and 

beneficiaries are responsible for part of the cost of these services through

cost sharing.5

 For all beneficiaries, Medicare covers the physician’s 

interpretation of ultrasound exams under Part B. For beneficiaries in a 

Part A-covered SNF or hospital inpatient stay, Medicare covers most 

services under Part A and pays for them through a prospective payment 

system (PPS), which involves bundling payment for multiple services. 

Specifically, for beneficiaries in Part A-covered SNF stays, payment for 

ultrasound exams and medically necessary ambulance transportation is 

bundled with other services into a single daily rate. A PPS gives providers 

the incentive to furnish services efficiently because if the actual cost of 

services is less than the bundled payment, the provider keeps the 

difference. For beneficiaries who are not in a Part A-covered SNF or 

hospital inpatient stay, which includes those in a noncovered SNF stay, 

Medicare covers ultrasound exams and medically necessary ambulance 

transportation under Part B. 

 3

CMS refers to ultrasound exams as “technical components” and physicians’ interpretations 

of images from these exams as “professional components.” 

4

CMS is an agency within the Department of Health and Human Services (HHS), to which 

HHS has delegated responsibility for administering the Medicare program.

5

Medicare Part A covers inpatient hospital, skilled nursing facility, hospice care, and some 

home health care. 

Page 2 GAO-07-734 Medicare Diagnostic Ultrasound Services
The rapid growth in spending for imaging has contributed to interest in the 

Congress and the Medicare Payment Advisory Commission (MedPAC) 

about whether Medicare’s payment methodology for these services creates 

the proper incentives for appropriate use. Further, MedPAC has expressed 

concern that not all imaging providers have the ability to conduct quality 

exams, and several ultrasound-related professional organizations have 

raised this issue with regard to sonographers. Becoming credentialed by a 

nationally recognized organization,6

 which can require obtaining a 

combination of training and experience and passing an examination, is one 

way for sonographers to demonstrate that they have the necessary skill 

level to perform quality exams. In addition, accreditation is a mechanism 

for facilities that conduct ultrasound procedures to demonstrate that their 

affiliated sonographers meet the standards necessary to perform quality 

exams. For example, to work in an accredited facility, sonographers may 

be required to have certain credentials or be working toward obtaining 

them. 

The Medicare Prescription Drug, Improvement, and Modernization Act of 

2003 required that we assess issues associated with providing ultrasound 

procedures to Medicare beneficiaries.7

 As discussed with the committees 

of jurisdiction, we address the following issues in this report: (1) the types 

of ultrasound procedures commonly used to diagnose medical conditions 

of Medicare beneficiaries, particularly those in SNFs, (2) the financial 

impact of changing how Medicare pays for ultrasound exams and 

associated equipment and ambulance transportation for beneficiaries 

receiving care in a SNF, and (3) the factors to consider in determining 

whether CMS should establish credentialing or other qualification 

requirements for sonographers. 

To examine the types of diagnostic ultrasound procedures provided to 

Medicare beneficiaries and the sites of service where the exams were 

performed, we analyzed Medicare claims data for 2005.8

 Our analysis of the

types of procedures provided to all Medicare beneficiaries was based on 

claims for physicians’ interpretations of ultrasound exams, which are paid

under Part B regardless of whether the exam itself was covered under 

 6

The American Registry for Diagnostic Medical Sonography (ARDMS) is one example of a

nationally recognized organization that credentials sonographers.

7

See Pub. L. No. 108-173, § 513, 117 Stat. 2066, 2300. 

8

The claims data that we used came from the National Claims History (NCH) carrier file, 

and the Standard Analytical File (SAF) outpatient claims files. 

Page 3 GAO-07-734 Medicare Diagnostic Ultrasound Services
Part A or Part B. Our analysis of the site of service of ultrasound 

procedures was based on claims for ultrasound exams that were paid 

under Part B because Part A payments for these exams are bundled with 

other services and not separately reported in the Medicare claims data. To

understand clinical issues associated with the site of service, we 

performed a literature search; conducted structured interviews with 

representatives of gerontological, radiological, and other ultrasoundrelated professional organizations; and reviewed CMS documents.9

 To 

estimate the financial impact to Medicare and its beneficiaries of providing 

payments for ultrasound equipment transportation and of paying 

separately for ultrasound exams and associated equipment and ambulance 

transportation for beneficiaries in Part A-covered SNF stays, we analyzed

Medicare claims data for ultrasound exams and ambulance services in 

2005 and for exams in 1995 through 1997.10 We found the Medicare claims 

data we analyzed to be sufficiently reliable for the purposes of this 

report.11 To identify factors to consider in determining whether CMS 

should establish credentialing or other requirements for sonographers, we 

reviewed Medicare regulations, CMS documents, Medicare carriers’ 

credentialing requirements for sonographers, and relevant literature and 

also interviewed officials from agencies and organizations such as CMS, 

MedPAC, and those that credential sonographers.12 Appendix I provides 

more detail on our scope and methodology. We performed our work from

July 2006 through May 2007 in accordance with generally accepted 

government auditing standards. 

 9

The organizations interviewed included the American Geriatrics Society, the American 

Medical Directors Association, the American College of Radiology, the American Society of 

Echocardiography, the Society for Vascular Surgery, and the Society for Vascular 

Ultrasound; four mobile ultrasound providers that provide services to SNFs and nursing 

homes in various states; and representatives from the National Association for the Support 

of Long-Term Care and the American Association of Homes and Services for the Aging.

10Medicare only covers ambulance transportation that is medically necessary. See CMS,

Medicare Benefit Policy Manual, Chapter 10, §10.2, 10.2.1, May 28, 2004. 

11The Medicare claims data are used by the Medicare program as a record of payments to

health care providers and are monitored by CMS. 

12The credentialing organizations included the American Registry for Diagnostic Medical 

Sonography (ARDMS), the Intersocietal Commission for the Accreditation of Vascular 

Laboratories (ICAVL), and the American Institute of Ultrasound in Medicine (AIUM). 

Page 4 GAO-07-734 Medicare Diagnostic Ultrasound Services
The most common diagnostic ultrasound procedures provided to all 

Medicare beneficiaries and to those in noncovered SNF stays were used to 

diagnose heart and circulatory (vascular) problems. Echocardiograms, 

used to diagnose conditions such as heart failure and problems with the 

innermost layer of the heart, were the most frequently performed type of 

ultrasound procedure in 2005. They accounted for about 53 percent of the 

41 million procedures provided to nearly 12.4 million Medicare 

beneficiaries in any setting and 49 percent of the $3.2 billion in Medicare 

Part B payments for ultrasound procedures. Noninvasive vascular 

studies—used to examine the blood flow through veins and arteries and to 

detect blockage, injury, or blood clots—represented about 20 percent of 

the ultrasound procedures and 30 percent of the Medicare Part B 

payments. Nearly all (99 percent) of the ultrasound exams provided to 

beneficiaries under Medicare Part B in 2005 were performed in physician 

offices and hospital outpatient departments. The remaining 1 percent were

conducted in various sites of service, including about 129,000 exams 

conducted in SNFs and 101,000 exams conducted in beneficiaries’ homes. 

Among the ultrasound exams provided in SNFs to beneficiaries in 

noncovered SNF stays, noninvasive vascular studies were the most 

prevalent, followed by echocardiograms. 

Results in Brief 

We examined two potential changes to Medicare payment methods related 

to ultrasound procedures for beneficiaries in SNFs and found that both are 

likely to increase Medicare expenditures and beneficiary cost sharing 

based on 2005 data and assuming that the provision of exams would not 

change in response to this policy. First, we found that providing Part B 

payments to transport equipment to SNFs during noncovered SNF stays 

for ultrasound exams could have increased Medicare expenditures by 

about $9.8 million and beneficiary cost sharing by about $2.6 million in 

2005. Second, we estimated the impact of paying separately under Part B 

for ultrasound exams and associated equipment and ambulance 

transportation for beneficiaries in Part A-covered SNF stays, as opposed to 

bundling these services into the Part A PPS payment as is currently done. 

We found that this policy could have increased Part B Medicare 

expenditures by about $22.0 million and beneficiary cost sharing by about 

$13.4 million in 2005. However, these types of changes in payment policies 

could affect service use and thus could cause the actual financial impact to 

differ from our estimates. For example, paying separately under Part B for 

ultrasound exams and associated equipment and ambulance 

transportation for beneficiaries in Part A-covered SNF stays could cause 

the use of these services to grow because the PPS incentive to provide 

them efficiently would be absent, and this could cause the actual financial 

impacts to be greater than our estimates. In addition, unless these separate

Page 5 GAO-07-734 Medicare Diagnostic Ultrasound Services
Part B payments were offset by a reduction in the Part A PPS payment, 

they would increase overall Medicare expenditures. 

Factors for CMS to consider in determining whether to establish 

credentialing or other requirements for sonographers include the evidence 

of the value of establishing such requirements and the variation in federal

requirements for sonographers. Having qualified sonographers is 

important because their skill in performing an ultrasound exam is critical 

to capturing quality images that physicians can use in making appropriate 

clinical decisions and avoiding misdiagnoses or unnecessarily repeated 

exams. Findings from peer-reviewed studies, MedPAC, and ultrasoundrelated professional organizations support the establishment of 

qualification requirements for sonographers. In some locations and 

practice settings, Medicare mandates that certain sonographers either be 

credentialed or work in an accredited facility that requires sonographers 

to demonstrate that they meet certain quality standards. The inconsistency 

of Medicare’s requirements across the country, coupled with the absence 

of state licensure requirements for sonographers, undermines the 

assurance that beneficiaries are receiving similarly high-quality services in

different locations and settings. 

To help ensure consistency in the quality of ultrasound services provided 

to Medicare beneficiaries nationwide, we recommend that the 

Administrator of CMS require that sonographers serving Medicare 

beneficiaries either be credentialed or work in an accredited facility. 

In its written comments on a draft of this report, CMS stated that it would 

consider our recommendation but would prefer that states engage their 

own licensing bodies in implementing sonographer licensure programs. 

(See app. VI.) CMS stated that a national policy would not take into 

account regional variation in factors such as access to care and state 

licensing requirements. We agree that access is an important issue when 

considering whether to implement a national policy, and our report states 

that a regulation could include a phase-in period to provide 

noncredentialed sonographers with time to comply with the newly 

imposed requirements. Furthermore, although CMS asserted that states 

should engage their own licensure bodies to implement sonographer 

licensure programs, we reported that state licensing requirements for 

sonographers do not exist. Consequently, we continue to believe that CMS 

should implement our recommendation and develop a national policy 

establishing sonographer qualification requirements. 

Page 6 GAO-07-734 Medicare Diagnostic Ultrasound Services
Ultrasound is a noninvasive form of imaging that, unlike X-ray and certain 

other diagnostic modalities, does not expose patients to the risks 

associated with the emission of ionizing radiation. To perform a diagnostic 

ultrasound exam, a sonographer applies a hand-held medical device called 

a transducer to the skin through which the ultrasound machine emits and 

receives sound waves. As the sonographer moves the transducer around 

the patient’s body, an image of the various organs or blood flow under 

study appears on a monitor. The sonographer electronically stores what he 

or she considers as the most diagnostically useful images. 

The ultrasound systems that sonographers use differ along multiple 

dimensions, including their types of transducers, documentation 

capabilities, and cost. The type and number of transducers on a given 

ultrasound system depend on the parts of the body to be examined and the 

conditions intended to be diagnosed. In addition, some ultrasound systems 

have additional documentation capability, which allows sonographers and 

other health care personnel to electronically transmit and display 

ultrasound images. According to the ultrasound device manufacturers with 

whom we spoke, an ultrasound machine can range in price from $20,000 to

$200,000 or more. Prices are partially based on the system’s features, such 

as the number and type of different transducers it has and its capacity to 

store and transmit data. 

Sonographers can demonstrate that they have the appropriate level of 

training and experience by becoming credentialed by a nationally 

recognized organization. The American Registry for Diagnostic Medical 

Sonography (ARDMS) and Cardiovascular Credentialing International 

(CCI) are two main sonographer credentialing organizations. Each 

organization has multiple pathways to becoming credentialed that are 

designed to account for differences in sonographers’ training and 

experience. CCI allows sonographers without formal education, but with 

experience in the field, to take its credentialing exam, but ARDMS requires 

that all sonographers have a combination of education and experience to

take its exam. 

Background 

Sonographer Credentialing 

and Training and Facility 

Accreditation 

Sonographers can obtain formal training through numerous education 

programs. For example, the Commission on Accreditation of Allied Health

Education Programs lists 151 programs for diagnostic medical 

sonographers, including associate’s degree programs from community 

colleges as well as bachelor’s degree programs. Individuals we spoke with 

from ultrasound-related professional organizations noted that, although 

Page 7 GAO-07-734 Medicare Diagnostic Ultrasound Services
sonographers are more likely than in the past to undergo formal training, 

there are still practicing sonographers who do not have it. 

Several organizations offer accreditation for facilities that conduct 

ultrasound procedures as a way to demonstrate that they meet the 

standards necessary to perform quality exams.13 To work in an accredited 

facility, sonographers may be required to have certain credentials or have 

received a minimum number of training hours. For example, sonographers 

working in facilities that are accredited by the Intersocietal Commission 

for the Accreditation of Vascular Laboratories (ICAVL) must either be 

credentialed or have a specified level of training and experience in 

sonography. Similarly, for a facility to become accredited by the American 

Institute of Ultrasound in Medicine (AIUM), the sonographers who work 

there must either be credentialed by ARDMS or become credentialed 

before re-accreditation, which occurs every 3 years.14 This allows new 

sonographers to obtain experience conducting exams, which they need to

be eligible to take a credentialing exam, such as from ARDMS and CCI. In 

addition to requirements for sonographers, accreditation can address 

broader aspects of ultrasound procedures, including qualification 

requirements for physicians, the condition of the ultrasound equipment, 

patient safety, images produced, and documentation. 

Medicare and Its Coverage 

Processes 

Medicare is the federally financed health insurance program for persons 

age 65 and older and certain individuals with disabilities.15 The program 

serves over 42 million beneficiaries. Eligible individuals are automatically 

covered by Part A, which helps pay for inpatient hospital, skilled nursing 

facility, and hospice care, as well as some home health care. Most eligible 

individuals elect to pay a monthly premium to obtain Medicare Part B 

coverage, which covers physician services, hospital outpatient services, 

and certain other services, such as physical therapy. In addition to the 

 13These organizations include the American College of Radiology, the American Institute of 

Ultrasound in Medicine, the Intersocietal Commission for the Accreditation of Vascular 

Laboratories, and the Intersocietal Commission for the Accreditation of Echocardiography 

Laboratories. 

14Certification by the American Registry of Radiologic Technologists is also acceptable if 

the facility is applying for accreditation in breast ultrasound. 

15Medicare also covers individuals with end-stage renal disease. 

Page 8 GAO-07-734 Medicare Diagnostic Ultrasound Services
premium, beneficiaries are required to pay an annual Part B deductible as 

well as coinsurance of 20 percent for most Part B services.16

Medicare covers items or services that are provided for by statute and that

meet the applicable criteria for coverage when furnished to a particular 

beneficiary. Decisions on the extent to which, and under what 

circumstances, Medicare will cover specific services, procedures, or 

technologies may be made by CMS or its contractors in a number of ways. 

At the national level, CMS can make National Coverage Determinations 

(NCD) that apply across the country. More typically, most coverage issues 

are decided on the local level through Local Coverage Determinations 

(LCD) or other decisions made by the contractors that pay Medicare 

claims. For Part B claims for physician services, the contractors that pay 

claims and create LCDs are generally called carriers.17 If an NCD or other 

authority does not provide specific guidance about the conditions for 

covering a service, procedure, or technology, the carrier has the discretion

to adopt an LCD to address the issue. LCDs only apply to a carrier’s 

service area or to the providers it serves. 

Medicare Payment for 

Ultrasound Procedures 

and Associated Ambulance 

and Equipment 

Transportation 

Medicare covers physicians’ interpretations of ultrasound and other 

imaging exams under Part B for all beneficiaries. For beneficiaries, except

for those in a Part A-covered hospital or SNF stay, Medicare also provides

Part B coverage of ultrasound and other imaging exams as well as 

medically necessary ambulance transportation. How Medicare pays for 

ultrasound exams and associated ambulance transportation for 

beneficiaries in a SNF depends on whether Medicare covers the stay under 

Part A.18 For beneficiaries in Part A-covered SNF stays, Medicare bundles 

 16Beneficiaries’ coinsurance can be higher than 20 percent for Part B-covered services

provided in a hospital outpatient facility. 

17CMS has begun a process of using competition to choose its Medicare claims processing 

contractors and is awarding new contracts to entities called Medicare Administrative 

Contractors. When this process is complete, these contractors will review and pay all 

Part B claims. 

18Medicare covers skilled nursing and rehabilitative therapy for beneficiaries being treated 

in SNFs for conditions related to a hospital stay lasting at least 3 days and occurring within 

30 days before admission to the SNF. For beneficiaries who qualify, Medicare pays under 

Part A for most necessary services, including room and board, nursing care, and ancillary 

services such as drugs, laboratory tests, and physical therapy, for up to 100 days per benefit 

period. A benefit period begins when a Medicare beneficiary is admitted to a hospital or a 

SNF and ends when he or she has not been an inpatient of these facilities for 60

consecutive days. Beneficiaries are responsible for a daily copayment after the 20th day of 

SNF care, regardless of the cost of services received. 

Page 9 GAO-07-734 Medicare Diagnostic Ultrasound Services
payment for one part of the ultrasound procedure—the exam—as well as 

associated ambulance transportation into the daily Part A PPS payment.19

When beneficiaries remain in a SNF after exhausting their Part A SNF 

benefits or if the SNF stay is not covered for some other reason, they are 

in a “noncovered” SNF stay during which Medicare covers ultrasound 

exams and medically necessary ambulance transportation under Part B. 

Although nearly all Medicare services provided to beneficiaries in Part Acovered SNF stays are paid through the Part A PPS payment, certain 

services are paid for separately under Part B.20 The Balanced Budget Act of

1997 (BBA) excluded from the Part A PPS payment all physician services 

for beneficiaries in Part A-covered SNF stays, which include

interpretations of ultrasound and other imaging exams, and provides for 

separate payments for these services under Part B.21 In addition, certain 

categories of services—for example, the exam for computed tomography 

(CT) scans, magnetic resonance imaging (MRI), and angiography—are 

excluded from the Part A PPS payment and are paid for separately under 

Part B when provided in a hospital outpatient setting. CMS identified these 

services as ones that “lie well beyond the scope of care that SNFs would 

ordinarily furnish.”22 (See table 1.) One of our previous reports noted that 

CMS considered the possibility of paying separately for certain ultrasound 

 19Under the SNF PPS, the SNF receives a single daily payment for almost all Part A- and 

Part B-covered services provided to a SNF resident. Certain items and services are 

excluded from the PPS by statute and thus are paid for separately under Part B. In

conjunction with the PPS, each SNF is responsible for billing Medicare for almost all 

services provided during a Part A-covered SNF stay, including services rendered by an

outside supplier. 

20For a discussion of the services paid for separately for beneficiaries in Part A-covered 

SNF stays, see GAO, Skilled Nursing Facilities: Services Excluded from Medicare’s Daily

Rate Need to be Reevaluated, GAO-01-816 (Washington, D.C.: Aug. 22, 2001).

21See Pub. L. No. 105-33, § 4432, 111 Stat. 251, 414-22. 

22See Health Care Financing Administration Program Memorandum A-00-01 (January 2000).

Page 10 GAO-07-734 Medicare Diagnostic Ultrasound Services
exams and associated ambulance transportation but decided not to do so

because they did not meet the criteria used to identify such services.23

Table 1: Medicare Payment Methodology for Selected Imaging Procedures and Associated Transportation for Beneficiaries in 

SNF Stays 

Part A-covered SNF stays Noncovered SNF stays 

Type of procedure or

transportation Ultrasound X-raya

CT scan, MRI, 

Angiographyb

Ultrasound X-raya

CT scan, MRI, 

Angiographyb

Imaging procedures 

Exam ● ● ○c○ ○ ○

Interpretation of exam ○ ○ ○ ○ ○ ○

Ambulance transportation 

associated with imaging examd

● ● ○c○ ○ ○

Source: GAO analysis of CMS guidance on Medicare payment methodology for SNF services. 

Legend: ● = bundled into SNF PPS payment; ○ = paid separately under Part B 

a

Does not include angiography. 

b

Angiography is a type of imaging procedure that involves the use of X-rays to develop images of 

arteries after dye is injected into the bloodstream.

c

Exams and associated ambulance transportation are only paid for separately under Part B if the 

exam is conducted in a hospital outpatient facility.

d

Medically necessary ambulance transportation is paid for separately from the PPS payment under 

Part B when associated with dialysis and with the following services if provided in a hospital 

outpatient department: cardiac catheterization, MRI, CT scan, certain ambulatory surgery procedures,

emergency services, radiation therapy, angiography, and lymphatic and venous procedures. See 

CMS, Skilled Nursing Facility Consolidated Billing as it Relates to Ambulance Services, MLN Matters

No. SE0433 (2005). 

Medicare does not make separate Part B payments to transport ultrasound 

equipment to a home or SNF for an exam. The transportation of the 

ultrasound equipment and sonographer is considered to be bundled into 

the ultrasound exam payment. However, Medicare does make separate 

 23See GAO-01-816. CMS used three criteria to identify services to be paid for separately 

under Part B during Part A-covered SNF stays—these services were required to be (1) high

cost, (2) infrequently needed by SNF beneficiaries, and (3) unlikely to be overprovided.

CMS decided that doppler flow studies, a type of ultrasound procedure, did not meet the

first or second of these criteria and thus should not be paid for separately under Part B.

Similarly, CMS decided that ambulance transportation not already paid for separately 

under Part B—for example, ambulance service to transport a beneficiary from a SNF to

another location for an ultrasound exam—should not be paid for separately because this 

service did not meet the first of these criteria. 

Page 11 GAO-07-734 Medicare Diagnostic Ultrasound Services
Part B payments for the transportation and set-up of equipment used to 

conduct diagnostic X-ray exams.24

Policy concerning payment for the transportation of ultrasound equipment

has changed over time. Prior to 1996, CMS did not have a national policy 

concerning the transportation of ultrasound equipment, but some of its 

carriers developed their own policies to cover it. In 1995, carriers for 14 

states and the northern part of California had a policy to reimburse 

providers for additional transportation costs associated with providing 

mobile ultrasound exams, as they did for mobile X-ray exams, which is 

another type of imaging service.25 However, beginning January 1, 1996, 

CMS determined that the statutory provision that provided coverage for 

the transportation of portable X-ray equipment did not provide this 

coverage for diagnostic ultrasounds and, therefore, carriers could no 

longer make separate Part B payments for the transportation of ultrasound 

equipment.26

 24Section 1861(s)(3) of the Social Security Act provides coverage of diagnostic x-rays 

furnished in a Medicare beneficiary’s place of residence. CMS determined that because of

the increased costs associated with transporting x-ray equipment to the beneficiary, 

Congress intended to provide an additional payment amount for the transportation of 

equipment for services furnished by an approved portable x-ray supplier. See 60 Fed Reg. 

63124, 63149 (1995). Thus, CMS established specific procedure codes to pay for the

transportation of portable x-ray equipment.

25In California, while the carrier for the northern part of the state paid for ultrasound

equipment transportation, the carrier for the southern part of the state did not. 

26CMS had also allowed carriers to develop their own policies concerning separate Part B

payments for the transportation of electrocardiogram equipment. However, beginning 

January 1, 1997, carriers were no longer able to do so. Section 4559 of the BBA temporarily 

restored separate payments for the transportation of equipment for EKG tests performed

during 1998 but not thereafter. This section did not address payments for the 

transportation of ultrasound equipment. See Pub. L. No. 105-33, § 4559, 111 Stat. 251, 464.

Page 12 GAO-07-734 Medicare Diagnostic Ultrasound Services
Echocardiograms and noninvasive vascular procedures accounted for 

about three-fourths of the approximately 41 million ultrasound procedures 

provided to Medicare beneficiaries in 2005 in any setting.27 Nearly all of the 

ultrasound exams paid under Part B were performed in physician offices 

and hospital outpatient departments. The remaining 1 percent were 

conducted in various sites of service, including SNFs and beneficiaries’ 

homes. Among the exams provided in SNFs to beneficiaries in noncovered 

SNF stays, noninvasive vascular studies were the most prevalent, followed 

by echocardiograms. 

Echocardiograms, used to diagnose heart conditions, and noninvasive 

vascular studies, often used to diagnose blood clots, were the most 

common diagnostic ultrasound procedures provided to Medicare 

beneficiaries in 2005. (See fig. 1.) 

The Most Common 

Medicare Ultrasound 

Procedures in 2005 

Were

Echocardiograms and 

Noninvasive Vascular 

Studies

About Three-Quarters of 

Ultrasound Procedures 

Provided to All 

Beneficiaries in 2005 Were 

Echocardiograms and 

Noninvasive Vascular 

Studies 

 27The total number of procedures (41 million) is based on analysis of Medicare claims data 

for physician interpretations of ultrasound exams. These data account for procedures 

provided to all Medicare beneficiaries regardless of setting and whether the exams were 

paid under Part A or Part B. 

Page 13 GAO-07-734 Medicare Diagnostic Ultrasound Services
Figure 1: Percentages of Total Procedures and Total Part B Medicare Payments for 

Ultrasound Procedures Provided to Beneficiaries, 2005 

11%

12%

20%

53%

7%

10%

30%

49%

Source: GAO analysis of Medicare Part B claims data for 2005.

Total procedures

(41 million)

Total Medicare payments

($3.2 billion)

Echocardiogram

Noninvasive vascular

Abdomen and pelvis

Head, neck, chest, and other

Ultrasound guidance

3% 3%

Notes: Percentages may not sum to 100 due to rounding. The number of procedures is based on

claims for physicians’ interpretations of ultrasound exams and claims for ultrasound procedures

classified solely as physician services that did not have a separately billed exam and physician’s 

interpretation of the exam. Medicare payments do not include beneficiary cost-sharing amounts. Our 

calculation of Medicare payments does not include payment for ultrasound exams that were provided 

to beneficiaries in Part A-covered SNF or inpatient hospital stays because Part A payments for these 

exams are bundled with other services and not separately reported in Medicare claims data. 

Specifically, of the 41 million total procedures provided to nearly 

12.4 million beneficiaries in 2005 in any site of service, the following apply. 

• Echocardiograms were the most frequently performed type of ultrasound, 

accounting for about 53 percent of the total number of procedures and 

49 percent of Medicare Part B payments. Echocardiograms are commonly 

used to diagnose medical conditions such as heart failure, problems with 

the innermost layer of the heart or the respiratory system, and disorders of 

the heart rate. 

Page 14 GAO-07-734 Medicare Diagnostic Ultrasound Services
• Noninvasive vascular studies represented about 20 percent of ultrasound 

procedures provided to beneficiaries and 30 percent of Medicare Part B 

payments for ultrasounds. Among other conditions, noninvasive vascular 

ultrasounds are used to monitor the blood flow through veins and arteries 

and to detect blockage, or blood clots. They are frequently used to 

diagnose deep vein thrombosis (DVT).28

• Ultrasounds of the abdomen and pelvis accounted for about 12 percent of

the ultrasound procedures and 10 percent of Medicare Part B payments for 

ultrasounds. Abdominal ultrasounds are commonly used to identify 

disorders of the kidney and ureter, tumors, and disorders of the urinary 

tract. 

• Ultrasounds of the head, neck, chest, and other ultrasound procedures, 

accounted for about 11 percent of the total number of Medicare 

ultrasound procedures and 7 percent of Part B Medicare payments. 

Cataracts and disorders of the breast were among the top medical 

conditions diagnosed with these procedures. 

• Ultrasound guidance procedures accounted for the remaining share—

about 3 percent of the number of procedures and Part B Medicare 

payments. Ultrasound guidance is used, for example, to direct the 

placement of a needle to withdraw fluid from the membrane surrounding 

the heart or lungs or to guide the performance of breast, liver, and prostate

biopsies. Some of these ultrasound procedures require the attendance of a 

physician in the room during the performance of the procedure. (In 

appendix II, see table 4 for details on the level of physician supervision 

required for different types of procedures and table 5 for the top five 

medical conditions diagnosed by type of procedure.) 

Our analysis of the available site-of-service data showed that nearly all 

(99 percent) of the 28 million ultrasound exams provided to beneficiaries 

under Part B in 2005 were performed in physician offices and hospital 

 28Deep vein thrombosis is a condition where a blood clot forms in a vein, usually in the 

lower leg. This condition can cause pain and swelling. If a clot breaks free and moves 

through the vascular system to the heart and lungs it can be fatal. 

Page 15 GAO-07-734 Medicare Diagnostic Ultrasound Services
outpatient departments—68 percent and 31 percent, respectively.29 The 

remaining 1 percent (about 387,000 exams) were conducted in various 

sites of service, including SNFs and beneficiaries’ homes. Of the 28 million 

ultrasound exams provided to Medicare beneficiaries under Part B, about 

129,000 were conducted in SNFs for beneficiaries in noncovered SNF stays 

and about 101,000 were conducted in beneficiaries’ homes. 

Of the 129,000 ultrasound exams conducted in SNFs for beneficiaries in 

noncovered SNF stays, noninvasive vascular procedures were the most 

common, accounting for 53 percent of the exams and 68 percent of the 

Medicare Part B payments.30 The noninvasive vascular procedures were 

used to diagnose conditions such as disorders of the soft tissues, skin 

conditions, and deep vein thrombosis. Echocardiograms were the second

most frequently performed ultrasound exam in SNFs for beneficiaries in 

noncovered SNF stays, representing 22 percent of the procedures and 

20 percent of Part B Medicare payments. Ultrasounds of the abdomen or 

pelvis were also common among this population, accounting for about 

17 percent of the ultrasound procedures and 10 percent of Medicare Part B 

payments. The remaining 8 percent of the procedures and 2 percent of 

Part B Medicare payments were for various other categories, including 

head, neck, and chest. Only 5 ultrasound guidance procedures were 

conducted in SNFs for this population in 2005. (See fig. 2 and table 6 in 

app. II, which shows the top 5 medical conditions diagnosed by type of 

procedure provided to beneficiaries in noncovered SNF stays.) Data 

limitations did not allow us to examine the site of service for 

approximately 262,000 ultrasound procedures provided to beneficiaries in

Part A-covered SNF stays, but our analysis of the types of procedures 

Noninvasive Vascular 

Studies Were the Most 

Prevalent Ultrasound 

Exams Provided in SNFs 

to Beneficiaries in 

Noncovered SNF Stays 

 29This number of exams is smaller than the total number of procedures discussed above 

(41 million total procedures) because it is based on the number of technical components 

(exams) associated with the image production, whereas the 41 million procedures are 

based on counts of the physician interpretations of the exam and the procedures classified 

solely as physician services. The 28 million exams excludes exams provided to 

beneficiaries in Part A-covered SNF or hospital inpatient stays that are bundled with other

services under Medicare Part A and not reported separately in the Part B data. 

30These were exams that cost about $14 million and were paid for separately under part B 

for beneficiaries whose SNF stay was not covered by Part A. Our site-of-service analysis of 

exams performed in SNFs focuses on beneficiaries that were not in Part A SNF stays

because the data did not allow us to identify site of service for beneficiaries in Part A SNF 

stays. As noted earlier, payment for procedures provided in SNFs for Part A beneficiaries 

are not reported separately in the Part B data. 

Page 16 GAO-07-734 Medicare Diagnostic Ultrasound Services
these beneficiaries received shows similar results to those provided in 

SNFs during noncovered stays.31

Figure 2: Percentages of Total Procedures and Total Part B Medicare Payments for 

Ultrasound Procedures Conducted in SNFs for Beneficiaries in Noncovered SNF 

Stays, 2005 

Notes: We based this analysis on claims for ultrasound exams and claims for ultrasound procedures 

classified solely as physician services that do not include a separately billed exam and physician’s

interpretation of the exam. Medicare payments in this figure do not include beneficiary cost-sharing 

amounts. Our calculation of Medicare payments does not include those for ultrasound exams that 

were provided to beneficiaries in Part A-covered SNF or inpatient hospital stays because Part A 

payments for these exams are bundled with other services and not separately reported in Medicare 

claims data. 

8%

17%

53%

22%

10%

68%

20%

Source: GAO analysis of Medicare Part B claims data for 2005.

Total procedures

(129,119)

Total payments

($14 million)

Echocardiogram

Noninvasive vascular

Abdomen and pelvis

Head, neck, chest, and other

Ultrasound guidance

0% 2% 0%

 31For example, vascular procedures were the most prevalent (44 percent of the procedures)

for this population, followed by echocardiograms (33 percent). Ultrasounds of the

abdomen and pelvis accounted for 12 percent of the ultrasound procedures provided to

those in Part A SNF stays. The remaining 11 percent of the procedures were for various

other categories, including ultrasound guidance. 

Page 17 GAO-07-734 Medicare Diagnostic Ultrasound Services
Because of congressional interest in the quality of ultrasound services, and 

particularly those conducted in SNFs, we examined clinical considerations 

associated with the site where exams were performed. Our literature 

search produced no pertinent studies on clinical issues associated with 

transporting elderly patients to obtain ultrasound exams as opposed to 

providing mobile services in SNFs or beneficiaries’ homes. Our analysis of 

CMS’s 2005 data on the level of physician supervision required to perform 

ultrasound procedures indicates that about 90 percent of them did not 

require a physician to be present. Thus, having a sonographer provide 

these procedures could be appropriate for mobile services provided in a 

SNF or home even if a physician was not present. 

Representatives from nationally recognized professional organizations, 

including professionals in the fields of geriatrics and sonography, as well 

as ultrasound providers and long-term care provider organizations, 

provided their views on clinical considerations associated with 

transporting elderly patients to obtain an ultrasound or providing an 

ultrasound in a SNF.32 In general, they said that the risks and benefits 

depend on the patient’s condition—such as whether the beneficiary 

requires emergency care, the most appropriate setting for follow-up care,

and the type of ultrasound services provided. For example, there are risks 

in transporting elderly patients, particularly those with certain medical 

conditions including dementia, who can become disoriented in new 

surroundings.33 Some geriatricians, medical directors of SNFs, and longterm care providers said that moving patients could increase their risk of 

falls or fractures. A gerontologist and a geriatrician further noted that pain

is a major issue to consider in caring for frail, bedridden patients. 

Transporting patients with deep vein thrombosis and pressure sores may 

expose them to skin tears and pain. On the other hand, certain ultrasound 

exams may be best performed in hospitals or physician offices, according 

to organization representatives that we contacted. For example, some 

 32We conducted interviews with geriatricians and a gerontologist from the American 

Geriatrics Society and structured interviews with SNF medical directors who are members 

of the American Medical Directors Association. We also interviewed professionals from 

ultrasound-related organizations (the Society for Vascular Surgery, the Society for Vascular 

Ultrasound, and Society of Diagnostic Medical Sonography); four mobile ultrasound

companies that provide services to the elderly in SNFs or nursing homes; and 

representatives of the National Association for the Support of Long-Term Care and the

American Association of Homes and Services for the Aging. 

33In addition, patients may miss medication doses or meals, which can be serious for 

people with certain diseases, such as diabetes. 

Page 18 GAO-07-734 Medicare Diagnostic Ultrasound Services
beneficiaries may require emergency care, and therefore require 

hospitalization. Others who need ultrasound exams may have conditions

that involve risks of serious complications that could require surgical or 

other interventions more readily provided in a hospital. In addition, a 

hospital or physician’s office may be the best setting for certain types of 

procedures, such as ultrasound guidance for needle placement during 

biopsies, which requires the presence of a physician during the 

performance of the procedure. 

We addressed two potential changes to Medicare payment methods 

related to ultrasound procedures, both of which are likely to increase 

Medicare expenditures and beneficiary cost sharing.34 The first potential 

change we addressed, which would involve paying to transport equipment 

to SNFs during noncovered SNF stays for ultrasound exams, could have 

increased Medicare expenditures by an estimated $9.8 million and 

beneficiary cost sharing by an estimated $2.6 million in 2005, assuming 

that this policy change would not affect the number and location of exams 

provided. The second potential change in Medicare payment methods 

involves paying separately under Part B for ultrasound exams and 

associated equipment and ambulance transportation during Part Acovered SNF stays, as opposed to bundling payments for these services as 

is done now. We found that paying separately under Part B for these 

services could have increased Part B Medicare payments by an estimated

$22.0 million and beneficiary cost sharing by an estimated $13.4 million in 

2005, assuming no change in the number of services provided as a result of

this policy. However, because these revised payment policies could affect

the use of these services, the actual financial impacts could differ from our 

estimates. For instance, paying separately under Part B for ultrasound 

exams and associated equipment and ambulance transportation during 

Part A-covered SNF stays could cause the use of these services to grow 

because the PPS incentive to provide services efficiently would be absent,

so the actual impact of this policy could exceed our estimates. Further, 

unless these separate Part B payments were offset by a reduction in the 

Part A PPS payment, they would increase overall Medicare expenditures. 

Changing Ultrasound 

Payment Methods 

Would Likely Increase 

Expenditures and 

Beneficiary Cost

Sharing 

 34The financial impact estimates in this section are based primarily on Medicare claims data 

for 2005. Since 2005, there have been changes that could affect the use of ultrasound exams

and associated equipment and ambulance transportation and thus also affect our estimates. 

These changes include those related to Medicare payment methodology as well as other 

changes, such as technological advances, that could affect service use. However, 

accounting for changes that occurred since 2005 and those that could occur in the near

future is beyond the scope of this report. 

Page 19 GAO-07-734 Medicare Diagnostic Ultrasound Services
Part B Equipment 

Transportation Payments 

Would Likely Increase 

Expenditures and 

Beneficiary Cost Sharing 

Paying to transport ultrasound equipment for the 129,000 exams done in 

SNFs during noncovered SNF stays in 2005 could have increased Medicare 

expenditures by an estimated $9.8 million and beneficiary cost sharing by 

an estimated $2.6 million, assuming the number and location of exams 

would not have changed in response to this policy. If this policy also 

applied to mobile exams conducted in other sites of service, the financial 

impact could be greater. For example, if Medicare made separate Part B 

payments to transport ultrasound equipment to beneficiaries’ homes, as is 

the case for the transportation of portable X-ray equipment, the financial 

impact could be higher by about $4.4 million for Medicare expenditures 

and $1.2 million higher for beneficiary cost sharing. Similarly, paying to 

transport ultrasound equipment to custodial care and assisted living 

facilities could have increased the financial impact of this policy further

(see table 2). 

Table 2: Financial Impact of Part B Ultrasound Equipment Transportation 

Payments, 2005 

Financial impact

Site of service 

Ultrasound 

exams 

(number)

Medicare 

payments 

(dollars)

Beneficiary cost 

sharing

(dollars)

Skilled nursing facilitiesa129,119 $9.8 million $2.6 million

Home 101,285 $4.4 million $1.2 million

Custodial care and assisted 

living facilities 22,787 $1.3 million $0.3 million

Total 253,191 $15.5 million $4.1 million

Source: GAO analysis of Medicare Part B claims data for 2005. 

Notes: Dollar amounts may not sum to totals due to rounding. To calculate the number of ultrasound 

exams, we counted the exams themselves that were paid under Part B, as well as ultrasound 

procedures classified solely as physician services that do not include a separately billed exam. 

Ultrasound exams were defined as Healthcare Common Procedure Coding System codes in the 

Berenson-Eggers Type of Service categories for echography in addition to 10 diagnostic ultrasound 

codes that were not in these categories. Calculations are based on the assumption that mobile 

ultrasound providers would receive a fee for transporting and setting up the equipment. See appendix

I for more information on how we defined ultrasound exams and appendix III for detailed results. 

a

Based on exams conducted in either a SNF or nursing facility during a noncovered SNF stay. 

The actual financial impact of paying to transport ultrasound equipment to 

SNFs would differ from our estimates if this policy caused the number of 

mobile exams provided to increase or decrease, but this would not affect 

our determination that this policy would likely lead to higher Medicare 

expenditures and beneficiary cost sharing. The mobile providers we spoke 

with noted that Medicare payments to transport ultrasound equipment 

Page 20 GAO-07-734 Medicare Diagnostic Ultrasound Services
would allow them to expand their service area and thus could increase the

number of exams they provide. For example, one provider noted that 

transportation payments might allow it to serve beneficiaries in rural areas 

where doing so would have proved cost prohibitive before. Thus, 

payments to transport ultrasound equipment could potentially increase the 

number of mobile exams and provide more beneficiaries with access to 

these services. 

Increasing access to mobile ultrasound exams could possibly lessen the 

need for ambulance services to transport beneficiaries from a SNF to 

another location for an ultrasound exam, which could in turn reduce the 

financial impact of this policy. Mobile providers stressed that Medicare 

and its beneficiaries save money when beneficiaries in SNF stays receive

mobile exams in a SNF as opposed to being transported to another 

location, in part because payments and beneficiary cost sharing to 

transport ultrasound equipment are less than for an ambulance round trip. 

We identified about 13,900 exams that potentially could have been 

conducted in a SNF during a noncovered SNF stay rather than using 

ambulance transportation to travel to another location for the exam.35 If 

the increased availability of mobile exams allowed all of these 13,900 

exams to be conducted in a SNF rather than in the locations (such as a 

hospital outpatient facility) where they actually took place, the financial 

impact of this policy would have been about $3.0 million lower for 

Medicare expenditures and about $1.2 million lower for beneficiary cost 

sharing.36

However, if mobile providers increased the number of ultrasound exams 

conducted in SNFs and other locations, it is also possible that this increase 

could lead to larger than estimated increases in Medicare expenditures 

and beneficiary cost sharing. Some of the exams conducted for 

beneficiaries in noncovered SNF stays likely were conducted in other sites 

of service (for example, physicians’ offices or hospital outpatient 

departments) but did not involve Medicare-covered ambulance services to

 35See appendix I for how we identified these exams. 

36These estimates take into account that (1) ultrasound equipment transportation (if it were

covered) likely would, on average, be less expensive than ambulance transportation for 

Medicare and its beneficiaries—the average amount paid by Medicare and its beneficiaries

for ultrasound equipment transportation (including the equipment set-up fee) for each of

these 13,900 exams in 2005 was $138, compared to $514 for an ambulance round trip—and 

(2) Medicare expenditures and beneficiary cost sharing for an ultrasound exam can be

different in a SNF compared to other locations such as a hospital outpatient facility. 

Page 21 GAO-07-734 Medicare Diagnostic Ultrasound Services
transport the beneficiary there. If mobile providers furnished more 

ultrasound exams in SNFs by expanding their service area, some of these 

beneficiaries might have received exams in this site of service rather than

in other locations. As a result of this change in the site of service for these

exams, our estimated impacts on Medicare expenditures and beneficiary 

cost sharing could (1) increase because Medicare would be paying for the 

additional ultrasound equipment transportation cost that would otherwise 

not have been necessary and (2) change due to the different cost of the 

exams themselves in the new locations. However, data constraints do not 

allow us to estimate the extent to which this would occur.37

Based on what mobile providers told us, one might expect the number of 

mobile exams to increase in response to the provision of payments to 

transport ultrasound equipment. However, our analysis of the effect of 

ceasing to pay for ultrasound equipment transportation in 1996 indicates 

that the opposite might occur. In 1995, Medicare carriers in 14 states and 

Northern California paid to transport ultrasound equipment, but these 

payments ceased in all localities as of January of 1996. We compared the 

growth rate in the number of exams conducted in SNFs in the 14 states 

where Medicare paid to transport ultrasound equipment in 1995 and 

stopped doing so thereafter to the rate across all other states where this 

change did not occur.38 The number of exams conducted in SNFs grew by 

about 237 percent from 1995 to 1997 in states where Medicare paid to 

transport ultrasound equipment in 1995 and ceased doing so thereafter, 

which was substantially greater than the 62 percent growth rate in other 

states where Medicare had not paid to transport ultrasound equipment. 

This suggests that the elimination of Medicare payments to transport 

ultrasound equipment may have led to an increase in the number of mobile 

exams as the amount paid per exam decreased.39

 37We were only able to identify exams conducted during noncovered SNF stays if they were

conducted in a SNF or nursing facility because we did not have accurate data on which 

beneficiaries were in noncovered SNF stays. Therefore, we could not estimate the financial 

impact of a change in the site of service for exams conducted during noncovered SNF stays 

that were not conducted in a SNF or nursing facility.

38See appendix III, table 8, for detailed results of this analysis. We excluded California from

this analysis because the two Medicare carriers in this state did not have the same policy 

regarding payments to transport ultrasound equipment. 

39An increase in the number of exams conducted in SNFs following the elimination of

transportation payments does not necessarily imply that the opposite would occur if these 

payments were reinstated. 

Page 22 GAO-07-734 Medicare Diagnostic Ultrasound Services
These results raise the possibility that mobile providers might maintain or 

decrease the number of exams they provide if Medicare began paying to 

transport ultrasound equipment. A decrease in the number of exams 

conducted in SNFs, if it occurred, could require that more beneficiaries 

use ambulance services to be transported to other locations for the 

exams.40 We estimated that a reduction in the number of exams conducted 

in SNFs could cause the estimated increases in Medicare expenditures and 

beneficiary cost sharing to be greater. 

Paying separately under Part B for ultrasound exams and associated 

equipment and ambulance transportation during Part A-covered SNF 

stays, as opposed to bundling these services into the Part A PPS payment 

as is done now, could have increased Medicare Part B payments in 2005 by 

an estimated $22.0 million and caused beneficiary cost sharing to rise by 

about $13.4 million, assuming that this policy would not affect service 

use.41 (See table 3 and app. I for details on how these estimates were 

calculated.) 

Paying Separately for 

Ultrasound Services during 

Part A-Covered SNF Stays 

Would Likely Increase Part 

B Expenditures, 

Beneficiary Cost Sharing, 

and Service Use 

 40We have reported that about 40 percent of beneficiaries who received an ultrasound exam

in a nursing home would require ambulance services to be transported to another site of

service for the exam if mobile ultrasound services were unavailable. See GAO, Medicare: 

Impact of Changing Transportation Policy for Portable Equipment is Uncertain, 

GAO/HEHS-98-82 (Washington, D.C.: May 18, 1998). 

41These estimates include up to $2.6 million in Medicare payments and $1.5 million in 

beneficiary cost sharing for up to 33,000 ultrasound exams for which Medicare appears to

have improperly paid for separately under Part B. HHS’s Office of Inspector General (OIG)

is currently reviewing improper billing of services under Part B provided to beneficiaries in 

Part A-covered SNF stays that should have been covered under the PPS payment. OIG 

officials noted that Medicare contractors likely recouped these improper payments. 

However, if these contractors failed to recoup all of these improper payments, then we 

would have overestimated the financial impact of paying separately under Part B for these 

exams because Medicare would have already been paying separately under Part B for some

of them in the absence of this policy. Because data for improperly paid claims do not

indicate whether the payment was recouped, we are unable to accurately estimate the 

extent to which these improper payments affect our impact estimates. See appendix I for 

more detail. 

Page 23 GAO-07-734 Medicare Diagnostic Ultrasound Services
Table 3: Increase in Part B Expenditures and Beneficiary Cost Sharing Due to 

Separate Payments for Ultrasound Services during Part A-Covered SNF Stays, 2005 

Type of service

Increase in Part B 

expenditures 

(dollars) 

Increase in beneficiary 

cost sharing

(dollars)

Ultrasound examsa$19.5 million $12.7 million

Ultrasound equipment 

transportationb

$2.3 million $0.6 million

Ambulance transportation for 

ultrasound examc

$0.2 million $0.1 million

Total $22.0 million $13.4 million

Source: GAO analysis of Medicare claims for 2005 and 1997 (see app. I for more detail). 

Notes: Dollar amounts may not sum to totals due to rounding. Ultrasound exams were defined as 

Healthcare Common Procedure Coding System codes in the Berenson-Eggers Type of Service 

categories for echography in addition to 10 diagnostic ultrasound codes that were not in these 

categories. See appendix I for more detail. 

a

Estimates based on physicians’ interpretations of ultrasound exams conducted during Part Acovered SNF stays and estimates of the Medicare payment and beneficiary cost sharing for the exam

that corresponds to these interpretations. See appendix I for more detail. 

b

Estimates based on the assumption that Medicare would pay for both the transportation and set-up 

of the ultrasound equipment. If Medicare only paid for the transportation of ultrasound equipment, 

Part B expenditures due to separate Part B payments during Part A-covered SNF stays for this

service would increase by about $2.0 million, and beneficiary cost sharing would increase by

approximately $0.5 million. 

c

Defined as ambulance services used to transport a beneficiary from a SNF to another facility and 

back for an ultrasound exam. 

The actual financial impact of paying separately under Part B for 

ultrasound exams and associated equipment and ambulance 

transportation could differ from the estimates in table 3 because this 

policy could cause their use to grow by undermining the incentive inherent 

in the PPS to efficiently provide these services. Although we did not find 

published studies specific to ultrasound or certain other imaging 

modalities predicting that this would occur, one of our previous reports 

found that bundling SNF services into a single PPS payment caused the 

use of therapy services to decrease.42 This suggests that paying separately 

under Part B for these services could possibly have the opposite effect and

cause use to grow, which could also cause the actual financial impact of 

this policy to exceed our estimates. Similarly, MedPAC has reported that

 42GAO, Skilled Nursing Facilities: Providers Have Responded to Medicare Payment 

System By Changing Practices, GAO-02-841 (Washington, D.C.: Aug. 23, 2002). 

Page 24 GAO-07-734 Medicare Diagnostic Ultrasound Services
there are efficiency gains from bundling payments.

43 In addition, both we 

and MedPAC have previously noted that bundling Medicare payments for 

certain end-stage renal disease drugs together with other items for this 

condition could improve efficiency by eliminating the financial incentive 

to overuse separately billable drugs.44 Furthermore, we have reported that

the home health PPS, which involves paying home health agencies a single

bundled payment per 60-day episode of care, provides strong financial 

incentives to reduce the cost of providing home health care.45

Paying separately under Part B for ultrasound exams and associated 

equipment and ambulance transportation also would increase overall

Medicare payments for these services unless the additional Part B 

expenditures were offset by payment reductions for other services. 

Congress chose to do this on a previous occasion.46 Thus, if Congress 

instituted separate Part B payments for ultrasound exams and associated

equipment and ambulance transportation during Part A-covered SNF 

stays, these payments could possibly be made budget neutral by a 

reduction in the Part A PPS payment. However, making this policy budget

neutral would require that the Part A PPS payment reduction account for 

the potential of increased service use associated with unbundling services. 

 43Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment 

Policy (Washington, D.C.: March 1999). 

44See GAO, End-Stage Renal Disease: Bundling Medicare’s Payment for Drugs with

Payment for All ESRD Services Would Promote Efficiency and Clinical Flexibility, 

GAO-07-77 (Washington, D.C.: Nov. 13, 2006) and Medicare Payment Advisory Commission, 

Report to the Congress, Medicare Payment Policy (Washington, D.C.: Mar. 2001). 

45GAO, Medicare Home Health Care: Payments to Home Health Agencies Are 

Considerably Higher than Costs, GAO-02-663 (Washington, D.C.: May 6, 2002). 

46On the basis of recommendations from CMS, Congress mandated in the Balanced Budget

Refinement Act of 1999 that Medicare pay separately under Part B for certain services (for

example, chemotherapy and customized prosthetic devices) during Part A-covered SNF

stays. See Pub. L. No. 106-113, div. B, § 1000(a)(6) [H.R. 3426, title I, sec. 103(a)], 113 Stat. 

1501, 1536 and 1501A-325-326 (codified at 42 U.S.C. § 1395yy(e)(2)(A)(iii)). In doing so, 

Congress required that CMS reduce the Part A PPS payment to offset the increase in Part B 

expenditures resulting from paying separately for these services. 

Page 25 GAO-07-734 Medicare Diagnostic Ultrasound Services
Factors for CMS to consider in determining whether to establish 

credentialing or other qualification requirements for sonographers include 

findings about the value of credentialing from peer-reviewed studies, 

MedPAC, and ultrasound-related organizations, coupled with variation in 

federal requirements and lack of state requirements for sonographers. 

Options available to CMS for promoting the quality of ultrasound services 

include specifying sonographers’ qualifications via a National Coverage 

Determination (NCD), promulgating a regulation, and offering a financial 

incentive for quality improvements through “pay for performance” 

mechanisms. 

Sonographer qualifications play an important role in the quality and 

diagnostic usefulness of ultrasound procedures. Representatives from 

ultrasound-related professional organizations described ultrasound 

procedures as highly operator dependent. In addition, they noted that the 

accuracy and diagnostic usefulness of the images captured depends on the 

sonographer’s skills and abilities. When conducting diagnostic ultrasound 

procedures, the sonographer is responsible for obtaining quality images of

internal body parts to enable the physician to make correct diagnoses of 

patients’ diseases and medical conditions. Two studies have shown that 

poor quality images can lead to misdiagnosis or unnecessarily repeated 

exams.47 Representatives of some ultrasound-related professional 

organizations that we interviewed noted that the increased use of 

ultrasound procedures in clinical practice and sophistication of the 

equipment have heightened the need for sonographers to undergo formal 

training. Currently, about 50 to 60 percent of the sonographers have the 

appropriate credentials, according to ARDMS estimates. 

Evidence and 

Variation in Federal 

Requirements Are 

Among Factors to 

Consider in 

Determining Whether 

to Establish 

Credentialing or 

Other Qualification 

Requirements for 

Sonographers 

Studies and Professional 

Organizations Suggest that 

Setting Requirements for 

Sonographers’ 

Qualifications Could 

Promote Quality 

 47See D. G. Stanley, “The Importance of Intersocietal Commission for the Accreditation of 

Vascular Laboratories (ICAVL) Certification for Noninvasive Peripheral Vascular Tests: The 

Tennessee Experience,” The Journal for Vascular Ultrasound, vol. 28, no. 2 (2004) and 

O. William Brown, et al., “Reliability of Extracranial Cartoid Artery Duplex Ultrasound 

Scanning: Value of Vascular Laboratory Accreditation,” Journal of Vascular Surgery, 

vol. 39, no. 2 (2004). 

Page 26 GAO-07-734 Medicare Diagnostic Ultrasound Services
While studies that demonstrate the need for credentialing and 

accreditation have been limited in number and scope, those that exist 

seem to suggest that imposing credentialing or other qualifications on 

sonographers can improve the accuracy of ultrasound procedures.48 For 

example, two of the four relevant peer-reviewed studies from our 

literature review found that the results of noninvasive vascular ultrasound 

exams done by accredited facilities were more accurate than those exams 

by nonaccredited facilities.49 The authors of these studies emphasized the 

importance of accurate ultrasound exams for clinical decisions that 

vascular surgeons make about patient treatment. 

Medicare experience with another type of imaging—mammography—also 

suggests that establishing federal standards that include requirements for 

personnel qualifications and facility accreditation could improve quality.50

In contrast to diagnostic ultrasound procedures, the Food and Drug 

Administration (FDA) established and enforces national quality standards 

for mammography services, which appear to have improved the quality of 

these procedures.51 Among other provisions in these standards, FDA 

established qualifications and continuing training requirements for 

mammography personnel, such as radiological technologists who perform 

the examinations, and also required facility accreditation.52 We previously 

reported that these quality standards, in conjunction with state inspection 

 48See appendix IV for summaries of the studies discussed in this section. 

49See D. G. Stanley, “The Importance of Intersocietal Commission for the Accreditation of 

Vascular Laboratories (ICAVL) Certification for Noninvasive Peripheral Vascular Tests: The 

Tennessee Experience,” p. 1, and O. William Brown, et al., “Reliability of Extracranial 

Cartoid artery duplex Ultrasound scanning: Value of vascular laboratory accreditation,” 

p. 369. 

50Mammography is an X-ray imaging procedure that can detect small tumors and breast 

abnormalities. 

51The Mammography Quality Standards Act of 1992, Pub. L. No. 102-539, § 2, 106 Stat. 3547, 

3547-61 amended by the Mammography Quality Standards Reauthorization Acts of 1998 

and 2004, Pub. L. No. 105-248, §§ 2-13, 112 Stat. 1864, 1864-67, Pub. L. No. 108-365, §§ 2-4, 

118 Stat. 1738, 1738-40, respectively, required that the HHS establish these standards. 

52FDA regulations also specify detailed requirements for qualifications and continuing

training for physicians who interpret the images and for mammography equipment and 

recordkeeping practices. See 21 C.F.R. § 900.12 (2006). 

Page 27 GAO-07-734 Medicare Diagnostic Ultrasound Services
programs, have increased mammography facilities’ adherence to accepted 

quality assurance standards and improved the quality of X-ray images.53

Furthermore, MedPAC and various ultrasound-related professional 

organizations with which we spoke support the implementation of a 

Medicare policy establishing requirements for the qualifications of 

sonographers. MedPAC recommended in 2005 that CMS “strongly 

consider” establishing standards for providers that perform and bill for 

imaging exams, which include diagnostic ultrasound procedures.54

MedPAC noted that these standards should address the qualifications of 

the performing technicians in addition to other aspects of imaging 

procedures.55 In addition, representatives from 11 ultrasound-related 

professional organizations support establishing requirements concerning

sonographers’ qualifications through sonographer credentialing and 

facility accreditation. (See app. V for a list of these organizations.) Of these 

11 organizations, 4 are ultrasound-related medical societies that do not 

credential sonographers or accredit facilities that conduct ultrasound 

procedures56 and the remaining 7 do.

Representatives from these organizations said that to conduct diagnostic 

ultrasounds, sonographers need to be trained and have broad knowledge, 

good judgment, and discretion. Representatives from the Society for 

 53See GAO, Mammography Services: Impact of Federal Legislation on Quality, Access, 

and Health Outcomes, GAO/HEHS-98-11 (Washington, D.C.: Oct. 21, 1997); Mammography

Quality Standards Act: X-ray Quality Improved, Access Unaffected, but Impact on

Health Outcomes Unknown, GAO/HEHS-98-164 (Washington, D.C.: May 8, 1998; 

Mammography Services: Initial Impact of New Federal Law Has Been Positive, 

GAO/HEHS-96-17 (Washington, D.C.: Oct. 27, 1995); and Mammography: Current 

Nationwide Capacity Is Adequate, but Access Problems May Exist in Certain Locations, 

GAO-06-724 (Washington, D.C.: July 25, 2006). 

54MedPAC also recommended that the Secretary of HHS select private organizations to 

administer these standards, and noted that CMS has similar “deeming” arrangements with 

private accreditation groups for several types of providers, such as hospitals and 

ambulatory surgical centers.” See Medicare Payment Advisory Commission, Report to the 

Congress: Medicare Payment Policy (Washington, D.C.: Mar. 2005). 

55MedPAC (2005) noted the following with regard to imaging services, which include

ultrasound procedures: “CMS should strongly consider setting standards for at least the 

following areas: the imaging equipment, qualifications of technicians, qualifications and

responsibilities of the supervising physician, technical quality of the images produced, and 

procedures for ensuring patient safety (for example, monitoring radiation exposure).” 

56These four organizations were the American Society of Echocardiography, the Society of 

Diagnostic Medical Sonography, the Society for Vascular Surgery, and the Society for

Vascular Ultrasound. See appendix V for descriptions of these organizations. 

Page 28 GAO-07-734 Medicare Diagnostic Ultrasound Services
Vascular Surgery stated that, because some procedures were done by 

inadequately trained technical staff or by facilities with little or no quality 

control, there are a “disturbing number” of patients who have (1) missed 

or delayed treatment of major health issues or (2) undergone unnecessary 

treatment due to abnormal results being classified normal or normal 

results being classified as abnormal. An article in a peer-reviewed journal 

reported that 91 percent of members of the Society for Vascular 

Ultrasound and the Society of Diagnostic Medical Sonography agreed that 

adding requirements for sonographer credentialing and facility 

accreditation would improve the quality of vascular ultrasound 

procedures.57

Some representatives of ultrasound equipment manufacturers and mobile 

ultrasound providers we interviewed also generally support sonographer 

credentialing. However, two of the manufacturer-related organizations we 

contacted and one provider were concerned that requirements for 

credentialing or accreditation could result in significant shortages of 

sonographers. Representatives from these manufacturer-related 

organizations noted that a phase-in period for establishing new 

requirements for sonographers would help prevent any potential access 

problems. Similarly, representatives of ultrasound-related professional 

organizations that we interviewed emphasized the importance of a phasein period to allow time for sonographers to become credentialed. 

Federal requirements relating to the qualifications of sonographers are 

inconsistent. This variation calls into question whether all sonographers 

paid by Medicare have appropriate and sufficient skills, knowledge, and 

experience to serve beneficiaries. Variation in federal requirements is also 

more of a concern because none of the states require that sonographers 

register or obtain a license from the state prior to providing ultrasound 

services, according to ultrasound-related professional organizations. At 

the federal level, CMS has not developed a national policy, such as an 

NCD, regarding the qualifications needed by sonographers as a condition

for payment of ultrasound services. In the absence of an NCD for 

sonographers’ qualifications, carriers have established Local Coverage 

Federal Requirements for 

Sonographers’ 

Qualifications Vary and 

State Requirements Are 

Absent 

 57See S. Boswell et al., “Practice Patterns and Membership Opinion About the Value of 

Credentialing and Accreditation: Results of a Membership Survey,” Journal of Diagnostic

Medical Sonography, vol. 19, no. 6 (2003), p. 390. 

Page 29 GAO-07-734 Medicare Diagnostic Ultrasound Services
Determinations (LCD) for different types of diagnostic ultrasound 

procedures. 

Allowing carriers to develop their own LCDs has resulted in varying 

Medicare requirements in different states for sonographers who perform 

particular types of diagnostic ultrasound procedures.58 For example, as of 

April 2007, carriers in 24 states and the District of Columbia have 

established one or more LCDs that require that noninvasive vascular 

diagnostic ultrasound procedures be performed by a credentialed 

sonographer (one that has undergone a certification process) or in an 

accredited facility that may require sonographers to meet certain 

qualification requirements.59 Carriers’ rationale was that the quality of 

these ultrasound procedures depends on the knowledge, skill, and 

experience of the sonographer. Carriers in 17 states have LCDs that 

recommend that noninvasive vascular diagnostic ultrasound procedures 

be performed by a credentialed sonographer or in an accredited facility. 

However, in the remaining 9 states, Medicare carriers have not established 

requirements through an LCD specifying the qualifications for 

sonographers who conduct noninvasive vascular ultrasound procedures. 

(See fig. 3.) Regarding mandatory requirements, a 2003 study that 

discussed reasons influencing a provider’s decision to obtain facility 

accreditation in vascular ultrasound cited a 1998 study that found that 

 58In 2003, we reported that giving Medicare contractors broad discretion to make local 

coverage policies had led to inequitable variations in coverage for beneficiaries depending

on where they were treated. We recommended that CMS develop and implement a plan to

evaluate the merits of existing coverage policies with the intent of incorporating 

appropriate aspects of local policies into national coverage policies and eliminating the 

remainder. See GAO Medicare: Divided Authority for Policies on Coverage of Procedures 

and Devices Results in Inequities, GAO-03-175 (Washington, D.C.: Apr. 11, 2003). CMS has

implemented a policy to consider and address policy variations, but the agency has not

considered developing an NCD concerning sonographers’ qualifications. 

59Accredited facilities may require that sonographers have certain credentials or a

combination of formal training and experience. 

Page 30 GAO-07-734 Medicare Diagnostic Ultrasound Services
providers are more likely to seek facility accreditation when it is required 

for Medicare payment.60 The 2003 study noted that “alternatives that 

consider voluntary compliance to ultrasound standards may be 

unsuccessful.”61

 60Among the other reasons that providers gave for obtaining facility accreditation was the

expectation that CMS would develop such a requirement and providers’ own interest in 

meeting medical practice standards. In contrast, some providers cited difficulty in meeting 

technical requirements, lack of staff or time resources, and expensive application fees as a

reason not to seek facility accreditation. The information about these reasons is based on a 

pilot study that the author conducted in 1998. See Kathleen M. Wilson, The Emergence and

Fall of the Ultrasound Quality Standards Act (H.R. 4217): Exploring the Interaction of 

Policy and Politics. Unpublished doctoral dissertation, University of Maryland, Baltimore

County, Baltimore, Md. (2003), p. 18. 

61See Kathleen M. Wilson, The Emergence and Fall of the Ultrasound Quality Standards

Act, p. 21. 

Page 31 GAO-07-734 Medicare Diagnostic Ultrasound Services
Figure 3: Medicare Carriers’ Part B LCDs on Noninvasive Vascular Diagnostic Ultrasound Procedures, as of April 2007 

Sources: GAO analysis of carriers’ Part B local coverage determinations concerning noninvasive vascular diagnostic ultrasound 

procedures and echocardiography. Copyright © Corel Corp. All rights reserved (map).

One or more LCDs require that the procedure be performed by 

a credentialed sonographer or in an accredited laboratory

One or more LCDs recommend that the procedure be performed by 

a credentialed sonographer or in an accredited laboratory

No LCD requires or recommends that the procedure be performed by

a credentialed sonographer or in an accredited laboratory

Pa.

Ore.

Nev.

Idaho

Mont.

Wyo.

Utah

Ariz. N.Mex.

Colo.

N.Dak.

S.Dak.

Nebr.

Tex.

Kans.

Okla.

Minn.

Iowa

Mo.

Ark.

La.

Ill.

Miss.

Ind.

Ky.

Tenn.

Ala.

Fla.

Ga.

S.C.

N.C.

Va.

Ohio

N.H.

Mass.

Mich. R.I.

Calif.

Wash.

Wis. N.Y.a

Maine

Vt.

W.Va.

Alaska

Hawaii

Conn.

N.J.

Del.

Md.

D.C.

a

The Medicare carrier in Queens, N.Y., does not have an LCD that includes a recommendation or 

requirement that noninvasive vascular diagnostic ultrasound procedures be performed by a 

credentialed sonographer or in an accredited laboratory. 

Page 32 GAO-07-734 Medicare Diagnostic Ultrasound Services
There is also variation in LCDs concerning diagnostic ultrasound 

procedures used to diagnose heart and other conditions. While carriers in 

12 states had developed LCDs as of April 2007 that require that these 

procedures be performed by a credentialed sonographer or in an 

accredited laboratory and carriers in 4 states had LCDs that recommended 

these types of qualifications for sonographers, the remaining states and 

the District of Columbia have no such LCDs. Finally, as of September 2006, 

carriers in 4 states had LCDs that established qualification requirements 

for sonographers that perform certain other diagnostic ultrasound 

procedures, such as abdominal and pelvic ultrasound. However, there are 

no similar LCDs in the remaining states and the District of Columbia. 

Variations in Medicare requirements regarding sonographers’ 

qualifications also relate to the sites of service where diagnostic 

ultrasound procedures are performed. For example, CMS has developed 

standards for nonphysician personnel that could be applicable to 

sonographers who perform diagnostic ultrasound procedures in 

independent diagnostic testing facilities (IDTF), but has not done so for 

physicians’ offices. For IDTFs, CMS requirements specify that

nonphysician personnel, including sonographers, who perform diagnostic 

ultrasound procedures, must demonstrate the basic qualifications to 

perform those procedures and have appropriate training and proficiency.

To meet this requirement, in the absence of a state licensing board, 

sonographers must be credentialed by an appropriate national

credentialing body.62 Furthermore, the IDTF must maintain documentation

available for review that Medicare credentialing requirements are being 

met. 

Although there are no Medicare standards specifically related to the 

qualifications of sonographers working in hospitals, Medicare providers 

need to abide by the relevant Medicare Conditions of Participation (CoP), 

some of which appear to be applicable to the performance of ultrasound 

procedures.63 There are CoP provisions that include specific standards for 

medical staff and for radiology,64 nuclear medicine, and outpatient 

services. According to the Medicare CoP for medical staff, hospitals are 

 62See 42 C.F.R. § 410.33(c) (2006). 

63CMS’s Conditions of Participation are requirements that health care organizations must 

meet in order to begin, and continue, participating in the Medicare program. 

64A CMS official told us that diagnostic ultrasound procedures are typically provided in

hospitals’ radiology departments. 

Page 33 GAO-07-734 Medicare Diagnostic Ultrasound Services
responsible for the quality of medical care provided to patients and must 

examine the qualifications and credentials of applicants for medical staff 

positions. If the hospital provides outpatient services, the CoP also 

requires that services must meet the needs of the patients in “accordance 

with acceptable standards of practice.” Further, hospital outpatient 

departments are required to have appropriate professional and 

nonprofessional personnel available. In 2003, over 80 percent of hospitals

met the applicable conditions of participation through accreditation from 

the Joint Commission on Accreditation of Healthcare Organizations (Joint 

Commission)—a nonprofit organization created to provide voluntary 

health care accreditation for hospitals.65

In contrast to IDTFs and hospitals, there are no Medicare standards that 

apply specifically to diagnostic ultrasound procedures conducted in 

physicians’ offices aside from those relating to the level of physician 

supervision required. The absence of qualification standards for 

sonographers working in physicians’ offices is of particular interest given 

MedPAC and the Lewin Group’s findings that there has been an increasing 

movement of imaging services, including ultrasound, from hospitals to 

physicians’ offices.66

CMS Has Several 

Implementation Options 

Several options are available to CMS for promoting the quality of 

diagnostic ultrasound procedures. Maintaining the status quo certainly 

imposes the least administrative burden and additional costs. However, 

this approach will not address the inconsistencies in requirements for 

sonographers’ qualifications. We present three options for promoting the 

quality of ultrasound procedures, with associated potential benefits and 

challenges. 

One option would be to develop an NCD requiring that sonographers 

either be credentialed or work in an accredited facility. Because NCDs 

apply to all Medicare beneficiaries regardless of their treatment locations, 

 65Hospitals may also apply to CMS for a review of their compliance with CoP, or through 

accreditation from the American Osteopathic Association, as an alternative to accreditation 

by the Joint Commission. CMS’s review is typically conducted by a state agency under

contract with CMS. 

66See Medicare Payment Advisory Commission (MedPAC), Report to the Congress, 

Medicare Payment Policy (March 2005), p. 154 and Lane Koenig et al, Lewin Group, An 

Analysis of the Use of Ultrasound Imaging Services in the Medicare Program, pp. 19-20 

(Washington, D.C.: 2005). 

Page 34 GAO-07-734 Medicare Diagnostic Ultrasound Services
an NCD would provide a more consistent level of assurance as to the 

qualifications of sonographers performing diagnostic ultrasound 

procedures. However, under the NCD option, CMS indicated it would have 

to implement the sonographer qualification requirements immediately 

rather than gradually over a period of time, according to a CMS official.67

This time constraint could be problematic given that representatives of 

various ultrasound-related societies and organizations we interviewed 

generally suggested a phase-in period of 2 or more years to allow 

noncredentialed sonographers time to comply with the newly imposed 

requirements. Finally, establishing an NCD could be difficult, according to

the CMS official, if it limited access to services for some beneficiaries, 

such as for those that lived in locations where no credentialed

sonographer was readily available. 

A second option would be to issue a regulation that establishes a 

requirement that sonographers either be credentialed or work in an 

accredited facility as a condition for Medicare payment. Such a regulation

could be phased in over 2 or more years, which as noted by 

representatives of ultrasound-related professional organizations we 

interviewed, would allow noncredentialed sonographers time to comply 

with this requirement. A CMS official noted that the regulatory process 

would allow CMS to use a phase-in period for establishing such a 

requirement but that developing regulations can be burdensome and time 

consuming for CMS. 

A third option would be for CMS to explore the possibility of “paying for 

performance” to encourage quality in the provision of diagnostic 

ultrasound procedures. CMS has recognized that the current Medicare 

reimbursement structure does not target resources to support specific 

efforts to provide the highest quality care. To address this shortcoming, 

CMS has initiated a number of demonstration and pilot projects, several 

required by Congress under statute, aimed at encouraging quality care and 

designed to lay the groundwork for pay-for-performance systems in the 

 67The CMS official explained that because Medicare pays for services that are reasonable 

and necessary, if clinical evidence supported the need for an NCD relating to qualification 

requirements for sonographers, CMS would not be in a position to allow a phase-in period.

Page 35 GAO-07-734 Medicare Diagnostic Ultrasound Services
future.68 However, these pay-for-performance efforts are in the early stages 

of development, and none of them is focused on imaging services or 

diagnostic ultrasound procedures. A CMS official and representatives of 

various ultrasound-related professional organizations told us that it is 

difficult to develop clear and valid quality measures that could be applied

to the performance of sonographers that conduct diagnostic ultrasound 

procedures. 

We did not find compelling clinical or financial evidence in favor of 

providing Part B payments for ultrasound equipment transportation in 

addition to those for the exams themselves, for beneficiaries in 

noncovered SNF stays. While testimonial evidence suggests that there may 

be benefits of performing ultrasound exams in SNFs for some 

beneficiaries as opposed to transporting them to other locations, we could 

not locate any studies documenting this. Furthermore, our analysis 

suggests that Part B payments for ultrasound equipment transportation 

could increase Medicare expenditures and beneficiary cost sharing. In 

addition, paying separately under Part B for ultrasound exams and 

associated equipment and ambulance transportation during Part Acovered SNF stays would undermine the financial incentive of the PPS for

SNFs to deliver these services efficiently. Paying separately under Part B 

for these services would also increase overall Medicare expenditures 

unless Congress made these additional Part B payments budget-neutral by

reducing the Part A PPS payment. 

Conclusions 

As a national program affecting over 42 million beneficiaries, Medicare has 

a responsibility to ensure that the services it covers are of consistently 

high quality. Our findings from peer-reviewed studies and MedPAC and 

ultrasound-related professional organizations, coupled with our analysis of

the variation in current requirements for sonographers, suggest that 

establishing requirements for sonographers’ qualifications could improve 

the quality of ultrasound procedures. Maintaining the status quo of 

allowing Medicare carriers to have different requirements for sonographer 

qualifications in different states undermines the assurance that 

 68For example, CMS has recently begun to implement the Medicare health quality 

demonstration, which is a 5-year program designed to achieve a number of goals, including

enhancing quality, improving patient safety, and increasing efficiency. In addition, CMS is 

coordinating with a number of stakeholders, including physicians, to develop and 

implement uniform, standardized sets of performance measures for various health care

settings. 

Page 36 GAO-07-734 Medicare Diagnostic Ultrasound Services
beneficiaries are receiving consistently high-quality services. CMS has 

several available implementation options including developing a National

Coverage Determination and promulgating regulations. 

We recommend that the Administrator of CMS require that sonographers 

paid by Medicare either be credentialed or work in an accredited facility. 

The Administrator should weigh the advantages and disadvantages of 

implementing a National Coverage Determination compared with 

promulgating regulations that this requirement be a condition for Medicare 

payment. 

In written comments on a draft of this report, CMS stated that while it 

would consider our recommendation to require that sonographers 

furnishing services to Medicare beneficiaries either be credentialed or 

work in an accredited facility, it would rather have states engage their own 

licensing bodies in implementing sonographer licensure programs that 

address competency and qualification issues. We reprinted CMS’s written 

comments in appendix VI. 

Recommendation for 

Executive Action 

Agency Comments 

and Our Evaluation 

CMS characterized our recommendation as providing two options—

issuing an NCD or promulgating a regulation establishing sonographer 

qualifications as a Condition of Participation—and stated that these 

options do not provide the most effective mechanism for addressing 

sonographer quality. We noted in our report that issuing a regulation was 

an option for CMS. However, we did not specify that this regulation apply 

only to ultrasound services furnished in or by providers that are subject to

Conditions of Participation (generally, institutional providers, such as 

hospitals) because we believe it is important that sonographer 

qualification requirements apply to all sonographers, regardless of the 

setting in which they provide the service, including physicians’ offices. 

CMS agreed with our finding that sonographer qualification requirements 

vary but stated that a national policy would not take into account regional 

variation in factors such as access to care and state licensing

requirements. We agree that access is an important issue when 

considering whether to implement an NCD or a regulation, and we pointed 

out that such a regulation could include a phase-in period to provide 

noncredentialed sonographers with time to comply with the newly 

imposed requirements. Furthermore, although CMS asserted that states 

should engage their own licensure bodies to implement sonographer 

licensure programs, we reported that state licensing requirements for 

sonographers do not exist. Consequently, we continue to believe that CMS 

Page 37 GAO-07-734 Medicare Diagnostic Ultrasound Services
should implement our recommendation and develop a national policy 

establishing sonographer qualification requirements. Such requirements, 

that sonographers paid by Medicare either be credentialed or work in an 

accredited facility, would help to promote the quality of ultrasound 

procedures across states and sites of service where consistent policy is 

currently lacking. 

CMS agreed with our conclusion that paying separately under Part B for 

ultrasound exams and associated equipment and ambulance 

transportation would undermine the financial incentive for SNFs to deliver 

these services efficiently. CMS further noted that paying separately for 

ultrasound exams could potentially lead to doing so for other services and 

lead to the “unraveling” of the SNF PPS bundle. 

We are sending copies of this report to the Administrator of CMS, 

appropriate congressional committees, and other interested parties. We 

will also provide copies to others on request. In addition, this report is 

available at no charge on the GAO Web site at http://www.gao.gov. 

If you or your staff have questions about this report, please contact me at

(202) 512-7114 or steinwalda@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff members who made contributions to this report 

are listed in appendix VII. 

A. Bruce Steinwald 

Director, Health Care 

Page 38 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

Page 39 GAO-07-734

Appendix I: Scope and Methodology 

This appendix explains the methodology that we used to address our 

reporting objectives on (1) the types of ultrasound procedures commonly 

used to diagnose medical conditions of Medicare beneficiaries, 

particularly those in skilled nursing facilities (SNF); (2) the financial 

impact of changing how Medicare pays for ultrasound exams and 

associated equipment and ambulance transportation for beneficiaries 

receiving care in a SNF; and (3) the factors to consider in determining 

whether the Centers for Medicare & Medicaid Services (CMS) should 

establish credentialing or other qualification requirements for 

sonographers that provide diagnostic ultrasound procedures. 

To examine the types of diagnostic ultrasound procedures provided to 

Medicare beneficiaries, medical conditions that were diagnosed, and sites 

of service where these procedures were performed, we analyzed Medicare 

claims for ultrasound procedures paid under Part B in 2005. These data 

came from the National Claims History (NCH) carrier file and the Standard 

Analytical File (SAF) outpatient claims files. We based our analysis of the 

types of procedures on claims for physicians’ interpretations of ultrasound 

exams, which account for procedures provided to all beneficiaries 

because all physicians’ interpretations of ultrasound exams are paid under 

Part B, regardless of whether the exam itself was paid under Part A or 

Part B.1

 We based our analysis of the site of service of ultrasound 

procedures on claims for ultrasound exams that were paid under Part B.2

Therefore, our site of service analysis does not cover exams for 

beneficiaries in Part A-covered SNF and hospital inpatient stays because 

Part A payment for these exams is bundled with other services and thus 

not separately reported in claims data. 

Types of Ultrasound 

Procedures Provided 

to Beneficiaries

To identify the specific diagnostic ultrasound procedures to analyze, we 

performed several steps. We began by developing a list of all the relevant 

diagnostic ultrasound procedures using information from the 2005 

American Medical Association (AMA) Current Procedural Terminology 

 1

In this analysis of the types of ultrasound procedures, we also included claims for 

ultrasound procedures classified solely as physician services that do not include a 

separately billed exam and physician’s interpretation of it. 

2

The Medicare Part B claims for ultrasound exam allowed us to identify the site of service 

where the sonographers produced the actual image. In this analysis of the site of service of 

ultrasound exams, we also included claims for ultrasound procedures classified solely as 

physician services that do not include a separately billed exam and physician’s 

interpretation of it. 

Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

(CPT) guide, and interviews with a credentialed sonographer with 

particular expertise in ultrasound coding and billing issues, and CMS 

officials, as well as documents provided during these interviews. We also 

reviewed the CMS Berenson-Eggers Type of Service (BETOS) codes, 

which categorize Healthcare Common Procedure Coding System (HCPCS) 

codes into clinically relevant categories.3

 For this report, we selected 94 

HCPCS codes in the BETOS categories for echography, which is a 

synonym for ultrasound.4

 We then supplemented these 94 codes with 10 

additional ones that we identified based on our review of codes in the 

AMA CPT Guide for 2005. The 104 total HCPCS codes we selected 

accounted for approximately 99 percent of all Medicare Part B payments 

for diagnostic ultrasound procedures in 2005.5

To analyze sites of service where ultrasound procedures were performed, 

we used Medicare data from the 2005 NCH carrier and SAF outpatient 

claims files. In addition, we used data and reviewed regulations from CMS 

on the appropriate level of physician supervision for each ultrasound 

procedure to examine how supervision levels varied across sites of 

service.6

 3

HCPCS is a standardized classification method used by CMS to identify medical, including

ultrasound, services and procedures. It is used in the submission to Medicare and other

insurers of claims for payment of services rendered by physicians and other providers. 

4

The six BETOS echography categories used to group HCPCS codes are as follows: (1) eye 

(category I3A), (2) abdomen/pelvis (category I3B), (3) heart (category I3C), (4) carotid 

arteries (category I3D), (5) prostate, transrectal (category I3E), and (6) other 

(category I3F). 

5

We supplemented the HCPCS codes in the BETOS categories for echography rather than 

using all HCPCS codes for diagnostic ultrasound procedures for two reasons. First, we

wanted to promote comparability with other studies that use the BETOS categories. 

Second, supplementing the HCPCS codes in the BETOS echography categories accounted

for virtually all (99 percent) of Medicare Part B spending on diagnostic ultrasound

procedures. 

6

CMS has established three levels of physician supervision for the technician who conducts

the exam component of ultrasound procedures and other diagnostic tests. The first level 

involves general supervision, which means that the procedure must be provided under the 

physician’s overall direction and control, but the physician’s presence is not required while 

the technician performs the exam. The second level involves direct supervision in the

office setting, which means that the physician must be present in the office suite and 

immediately available to furnish assistance and direction while the technician performs the 

exam. The third level involves personal supervision, which requires a physician to be in 

attendance in the room during the performance of the procedure. See appendix II for more

detail. 

Page 40 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

To examine clinical considerations associated with site of service and to 

supplement our data analysis on the medical conditions, we conducted a 

literature search and structured interviews with representatives of 

gerontological, radiological, and ultrasound-related professional 

organizations. Key search terms included transition of care, which 

involves moving the beneficiary from the SNF to another facility for the 

purpose of performing an ultrasound procedure; transfer trauma; patient 

transfers; and risks and morbidity associated with the movement of elderly 

persons to different settings. For the structured interviews, we contacted 

representatives from the American Geriatrics Society, the American 

Medical Directors Association, the American College of Radiology, the 

American Society of Echocardiography, the Society for Vascular Surgery,

and the Society for Vascular Ultrasound. In addition, we interviewed four 

mobile ultrasound providers that provide services to SNFs or nursing 

homes and representatives from the National Association for the Support 

of Long-Term Care and the American Association of Homes and Services 

for the Aging. We also conducted structured interviews with SNF directors 

of nursing in states selected based on criteria including their ultrasound 

use level per beneficiary.7

We estimated the financial impact of two changes in Medicare payment 

methodology for ultrasound exams and associated equipment and 

ambulance transportation for beneficiaries receiving care in a SNF. The 

first change we addressed was to make payments to transport and set up 

ultrasound equipment for exams conducted in SNFs during noncovered

SNF stays, which is not currently done. The second change involved 

paying separately under Part B for ultrasound exams and associated 

equipment and ambulance transportation during Part A-covered SNF 

stays. 

To estimate the financial impact of this potential change, we used 

Medicare Part B claims data for 2005 for ultrasound exams and ambulance 

services from the NCH carrier and SAF outpatient files. Based on these 

data, we (1) identified the number of exams conducted in SNFs during 

noncovered SNF stays, in beneficiaries’ homes, or in custodial care or 

Financial Impact of 

Changing Payment 

Methods 

Paying to Transport and 

Set Up Ultrasound 

Equipment 

 7

We obtained information from four directors of nursing in four states: Connecticut, 

Florida, New York and Pennsylvania. 

Page 41 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

assisted living facilities,8 (2) determined the number of beneficiary days on 

which these exams were conducted,9 and (3) multiplied the number of 

beneficiary days by our estimate of the average Medicare payment and 

beneficiary cost sharing for ultrasound equipment transportation, both 

including and excluding the equipment set-up fee, in the Medicare locality

where the claim was processed.10 Through these steps, we estimated how 

the expenditures of Medicare and its beneficiaries would have differed if 

Medicare had paid to transport and set up ultrasound equipment in 2005, 

assuming that the number and location of exams would not have changed

in response to this policy. (See app. III, table 7.) 

To gain insight into how Medicare payments to transport and set up 

ultrasound equipment would affect the number of ultrasound exams in 

SNFs during noncovered SNF stays, we used information from interviews 

and two types of analyses. First, we interviewed representatives of four 

mobile ultrasound providers. Second, we analyzed Part B claims data from 

the Part B Extract Summary System for 1995, when Medicare contractors 

in some states paid to transport and set up ultrasound equipment, and 

1997, when these payments were no longer provided.11 We compared the 

change between 1995 and 1997 in the number of ultrasound exams 

conducted in SNFs in 14 states that provided these payments in 1995 to the 

same measure in the remaining states that did not provide such 

 8

The number of exams includes ultrasound procedures classified solely as physician 

services that do not include a separately billed exam. To identify exams conducted in SNFs

during noncovered SNF stays, we first selected all Part B claims for ultrasound exams that 

were conducted in a SNF or nursing facility and then, based on claims for Part A-covered

SNF stays, we omitted those that were billed during Part A-covered SNF stays. 

9

The number of beneficiary days is defined as the sum across all beneficiaries in a given

site of service of the number of days on which ultrasound exams occurred for each

beneficiary. For example, if a beneficiary received at least one ultrasound exam on 

2 separate days, this beneficiary would contribute 2 beneficiary days to the total. 

10We based our estimate of the average Medicare payment and beneficiary cost sharing for 

ultrasound equipment transportation on the same measures for a similar service—the 

transportation and set-up fees for portable x-ray equipment transportation in 2005. 

11Carriers in the following 14 states provided these payments in 1995: Arizona, Connecticut, 

Delaware, Georgia, Iowa, Maine, Maryland, Massachusetts, Missouri, Nevada, New 

Hampshire, New Jersey, Pennsylvania, and Vermont. Transportation payments were also

made in Northern California, but not in the southern part of that state. 

Page 42 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

payments.12 (See app. III, table 8.) Third, we analyzed Part B claims data 

for ambulance services that appear to have been used in conjunction with 

ultrasound exams. 

If there was a decline in the number of ultrasound exams in SNFs during 

noncovered SNF stays in response to Medicare payments to transport and 

set up ultrasound equipment, it could cause the site of service of some 

exams to shift from these locations to other sites of service (such as a 

hospital outpatient facility). To determine whether this change in site of 

service would increase or decrease our impact estimates for paying to 

transport and set up ultrasound equipment, we accounted for how this 

change would affect Medicare expenditures and beneficiary cost sharing 

for (1) ambulance transportation,13 (2) the transportation and set up of 

ultrasound equipment, and (3) the ultrasound exam. 

Some ultrasound exams conducted during noncovered SNF stays may 

require ambulance services to transport the beneficiary to another 

location, such as a hospital outpatient facility, for the exam. To estimate 

how Medicare payments and beneficiary cost sharing would have differed 

in 2005 if these exams had instead been conducted in SNFs during 

noncovered SNF stays,14 we first identified ambulance trips used to 

transport these beneficiaries from SNFs to another location for an 

ultrasound procedure.15 We then calculated how Medicare payments and 

beneficiary cost sharing for the ultrasound exam and associated 

transportation would have differed if, rather than transporting the 

beneficiary via ambulance to another location, ultrasound equipment had 

 12We excluded California from our analysis because the policy regarding payments for

ultrasound equipment transportation and set up was not consistent throughout the state. 

For this analysis, we defined ultrasound exams as HCPCS codes in the BETOS categories

for echography and included exams in both SNFs and nursing facilities. 

13On the basis of our earlier work, we estimated that 40 percent of beneficiaries who 

received an ultrasound exam in a nursing home would need to be transported via 

ambulance if the exam were conducted at another site of service, such as a hospital 

outpatient facility. See GAO/HEHS-98-82. 

14To identify beneficiaries in noncovered SNF stays, we first used the origin and destination

of the ambulance trips to determine whether a beneficiary was in a SNF stay and then

omitted any beneficiary whose ultrasound exam, based on the SNF claims, occurred during

a Part A-covered SNF stay. 

15Ambulance trips for these beneficiaries (1) were on the same day as their ultrasound

exam, which was not conducted in a SNF during a noncovered SNF stay and 

(2) transported a beneficiary from a SNF to a physician’s office, hospital, or diagnostic or

therapeutic site (for example, an independent diagnostic testing facility) and back.

Page 43 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

been transported to the SNF for the exam. To estimate how conducting 

the exam in a SNF during a noncovered SNF stay rather than in another 

location would have affected Medicare payments and beneficiary cost 

sharing for transportation, we (1) calculated the number of beneficiary 

days on which these exams occurred, (2) determined the savings to 

Medicare and its beneficiaries per beneficiary day if, instead of 

transporting a beneficiary via ambulance to another location, ultrasound 

equipment were transported to the beneficiary for the exam, by 

subtracting our estimate of the ultrasound equipment transportation 

payment and cost-sharing amounts for each beneficiary day from the 

actual payment for ambulance services, and (3) multiplied this difference 

by the number of beneficiary days. To estimate the savings to Medicare 

and its beneficiaries for the exam itself, we subtracted the cost of 

conducting all of these exams in a SNF during noncovered SNF stays from 

the actual cost of these exams. 

The key limitation of our analysis of the financial impact of paying to 

transport and set up ultrasound equipment involves the accuracy of our 

assumption that this policy would not affect the number and location of 

ultrasound exams in SNFs during noncovered SNF stays. Therefore, to 

address the possibility that this policy change could affect ultrasound 

service use, we analyzed how such a change could affect our impact 

estimates. 

Paying Separately under 

Part B for Ultrasound 

Exams and Related 

Transportation during Part 

A-Covered SNF Stays 

To estimate the financial impact of paying separately under Part B for 

ultrasound exams and associated equipment and ambulance 

transportation during Part A-covered SNF stays, we analyzed claims for 

ultrasound exams and physicians’ interpretations of them for beneficiaries 

in Part A-covered SNF stays from Medicare Part B claims data for 2005 

from the NCH carrier file and the SAF outpatient claims files. We first 

counted the number of physicians’ interpretations of ultrasound exams 

that were conducted during Part A-covered SNF stays in 2005. We merged

Part B claims for physicians’ interpretations of ultrasound exams in 2005 

with SNF claims for the same year to determine which interpretations 

occurred during Part A-covered SNF stays. We then multiplied the number 

of physician interpretations of each exam by the average Medicare 

Page 44 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

payment and beneficiary cost-sharing amounts for the corresponding 

exam.16

Ultrasound exams and other services are bundled into the SNF 

prospective payment system (PPS) rate for beneficiaries in Part A-covered

SNF stays, so Medicare should not pay separately under Part B for these 

exams. However, we identified claims for up to 33,000 ultrasound exams 

conducted during Part A-covered SNF stays as having been improperly 

billed.17 Medicare paid approximately $2.6 million for these exams, and 

beneficiaries paid about $1.5 million. If Medicare contractors did not 

recoup all of these improper payments as they are required to, then our 

estimate of the financial impact of paying separately under Part B for 

ultrasound exams would be overstated because Medicare would have 

already been paying separately under Part B for some of these exams in 

the absence of this policy. However, because data for improperly paid 

claims do not indicate whether the payments were recouped, we were 

unable to accurately estimate the extent to which these improper 

payments affect our estimates.18

To estimate the financial impact of paying separately under Part B for 

ultrasound equipment transportation for beneficiaries in Part A-covered 

SNF stays, we first estimated the number of ultrasound exams conducted 

 16The average Medicare payment and beneficiary cost-sharing amounts for each HCPCS 

code were calculated based on Part B claims for ultrasound exams for all Medicare 

beneficiaries in 2005. Estimates for this analysis may slightly overstate the actual financial 

impact of separate Part B payments for ultrasound exams and associated equipment and

ambulance transportation because up to 5 percent of ultrasound exams conducted during 

Part A-covered SNF stays were on beneficiaries in critical access hospitals that may have

been certified as swing bed hospitals, which were not subject to the PPS. 

17The actual number of improperly paid exams and associated Medicare payments and 

beneficiary cost sharing may be slightly lower than these estimates because up to 3 percent

of these exams may have been conducted on beneficiaries in Part A-covered SNF stays 

who were in critical access hospitals that were certified as swing bed hospitals, which were 

not subject to the PPS. 

18The Office of Inspector General (OIG) of HHS is currently addressing the issue of 

improper billing for beneficiaries in Part A-covered SNF stays. For previous OIG reports on 

this issue, see HHS OIG, Review of Improper Payments Made by Medicare Part B for 

Services Covered Under the Part A Skilled Nursing Facility Prospective Payment System 

in Calendar Years 1999 and 2000, A-01-02-00513 (Washington, D.C.: May 2004); Review of 

Potential Improper Payments Made by Medicare Part B for Services Covered Under the 

Part A Skilled Nursing Facility Prospective Payment System, A-01-00-00538 (Washington, 

D.C.: June 2001); and Review of Compliance with the Consolidated Billing Provision 

Under the Prospective Payment System for Skilled Nursing Facilities, A-01-99-00531 

(Washington, D.C.: March 2000). 

Page 45 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

in SNFs, as opposed to other sites of service, for these beneficiaries in 

2005. To do so, we multiplied the number of physician interpretations of 

exams for these beneficiaries in that year by the proportion of all 

ultrasound exams for the same population in 1997 that were conducted in 

SNFs. We converted this estimate of the number of exams done in SNFs 

for these beneficiaries into the number of beneficiary days to indicate how 

many equipment transportation and set-up fees Medicare would have 

paid.19 To calculate the financial impact on Medicare payments, we added 

the product of (1) the number of beneficiary days and the average 

estimated equipment transportation fee and (2) the number of exams and 

estimated average of the equipment set-up fee. To calculate the financial 

impact on beneficiary cost sharing, we added the product of (1) the 

number of beneficiary days and the average estimated cost sharing for 

equipment transportation and (2) the number of exams and average

estimated equipment transportation fee.20

We used a similar process to estimate the financial impact of separate 

Part B payments for ambulance services used during Part A-covered SNF 

stays to transport beneficiaries from a SNF to another location for an 

ultrasound exam and back. We (1) estimated the number of ultrasound 

exams for beneficiaries in Part A-covered SNF stays in 2005 that involved

ambulance transportation, by multiplying the number of physician 

interpretations of exams for these beneficiaries in that year by the 

proportion of exams for the same population in 1997 that involved 

ambulance transportation; (2) converted this estimate of the number of 

exams involving ambulance transportation into the number of beneficiary 

days to indicate how many ambulance round trips Medicare would have 

 19Based on current payment policy for portable x-ray equipment transportation, when

multiple exams occur on a single beneficiary day (that is, during a single session for a given 

beneficiary), only one equipment transportation payment is required, although a set-up fee 

is paid for each exam. To convert the number of ultrasound exams conducted in SNFs to 

beneficiary days, we divided the number by the average number of these exams per 

beneficiary day based on Part B claims for exams conducted for beneficiaries in Part Acovered SNF stays in 1997—the most recent year for which these data were reported

separately for these beneficiaries. 

20As with the first component of our financial impact analysis, we based our estimate of the 

average Medicare payment and beneficiary cost sharing for ultrasound equipment 

transportation on the same measures for a similar service—the transportation and set-up 

fees for portable x-ray equipment in 2005. 

Page 46 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

paid;21 and (3) multiplied the number of beneficiary days by the average 

cost to Medicare and a beneficiary of an ambulance round trip. We also 

did a literature search to locate studies addressing the effect of the SNF 

PPS on the use of ultrasound and certain other imaging services. Key 

search terms included Medicare, skilled nursing facility, prospective 

payment system, ultrasound, imaging, X-ray, computed tomography, 

magnetic resonance imaging, and angiography. 

Our analysis of the financial impact of paying separately under Part B for 

ultrasound exams and related transportation has two key limitations. First, 

because more recent information was unavailable, we used 1997 data to 

estimate the number of ultrasound exams conducted in SNFs or that 

involved ambulance transportation.22 Therefore, the precision of estimates 

of the financial impact of paying separately under Part B for these services 

is limited by the accuracy with which the results based on the 1997 data

we used would have been similar if 2005 data had been available. In 

addition, the financial impact estimates we present are based on the 

assumption that service use would not change in response to this policy. 

To address the possibility that a policy of paying separately for services, as 

opposed to bundling payment for them, would affect the use of services, 

we (1) summarized studies we found that addressed how bundling 

payment for services can affect their use and (2) conducted a literature 

search to identify studies addressing how the use of certain imaging, and 

specifically ultrasound, services changed in response to the SNF PPS. 

 21To convert the number of ultrasound exams involving ambulance transportation to

beneficiary days, we divided the number by the average number of these exams per 

beneficiary day based on Part B claims for exams conducted for beneficiaries in Part Acovered SNF stays in 1997. 

22Data from 1997 are the most recent available for which the exams’ site of service was 

available for beneficiaries in Part A-covered SNF stays because, in 1998, CMS began 

phasing in the SNF PPS, which bundled payment for these and other services provided to

beneficiaries in Part A-covered SNF stays. 

Page 47 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix I: Scope and Methodology 

To identify factors to consider in determining whether CMS should 

establish credentialing or other qualification requirements for 

sonographers, we reviewed applicable Medicare regulations and CMS 

documents on Medicare coverage policies, including Medicare National 

Coverage Determinations. In addition, we reviewed Medicare carriers’ 

Local Coverage Determinations (LCD) related to the qualification 

requirements for sonographers that perform echocardiograms, 

noninvasive vascular ultrasounds, and other diagnostic ultrasounds, such 

as abdominal and pelvic ultrasounds. To identify these coverage policies, 

we conducted searches in CMS’s Medicare Coverage Database for draft 

and final LCDs related to echocardiograms and noninvasive vascular 

ultrasounds as of April 2007 for each Medicare carrier. We also conducted

a search in CMS’s Medicare Coverage Database for LCDs related to other 

diagnostic ultrasounds as of September 2006. 

In addition, we interviewed CMS and Medicare Payment Advisory 

Commission officials and representatives from national organizations that 

award credentials in sonography or accredit facilities that perform 

ultrasound procedures, and reviewed documents that they provided to us. 

These organizations included the American Registry for Diagnostic 

Medical Sonography, the Intersocietal Accreditation Commission,23 the 

American Institute of Ultrasound in Medicine, Cardiovascular 

Credentialing International, and the American College of Radiology. 

Finally, we conducted a literature search and reviewed relevant studies in 

peer-reviewed journals.

Medicare claims data, which are used by the Medicare program as a record 

of payments made to health care providers, are monitored by CMS. The 

data are subject to various checks and edits. Although we did not review

these checks and edits, we assessed the reliability of the NCH data, which 

include all claims data analyzed for this report. We found the data 

sufficiently reliable for purposes of this report. 

Factors to Consider 

Concerning 

Sonographer 

Qualification 

Requirements 

Data Reliability 

We performed our work from July 2006 through May 2007 in accordance 

with generally accepted government auditing standards. 

 23The Intersocietal Accreditation Commission has five subgroups: the Intersocietal 

Commission for the Accreditation of Vascular Laboratories, the Intersocietal Commission 

for the Accreditation of Echocardiography Laboratories, the Intersocietal Commission for 

the Accreditation of Nuclear Medicine Laboratories, and the Intersocietal Commission for 

the Accreditation of Magnetic Resonance Laboratories. 

Page 48 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix II: Ultrasound Procedures and

Medicare Part B Payments in 2005 

This appendix contains information on the number of ultrasound 

procedures provided to Medicare beneficiaries in 2005 by site of service

and the level of physician supervision required to administer the 

procedures. (See table 4.) This appendix also includes data on the five top 

medical conditions diagnosed by type of ultrasound procedures provided 

to Medicare beneficiaries overall and to those in SNF stays in 2005 that 

were not covered by Medicare. (See tables 5 and 6.) 

Table 4: Number of Ultrasound Procedures Provided to Medicare Beneficiaries by Site of Service and Level of Physician 

Supervision Required, 2005

Site of service

Type of ultrasound

procedure

Level of

physiciansupervision

required

Number of 

proceduresa

Physician’s 

office

Hospital 

outpatient 

department 

Skilled 

nursing 

facilityb

Other

c

Noninvasive vascular

General 6,347,815 3,821,749 2,376,169 69,704 80,193

Subtotal 6,347,815 3,821,749 2,376,169 69,704 80,193

Echocardiograms 

General 12,698,357 9,517,262 3,065,385 28,655 87,055

Direct 421,801 276,498 145,051 6 246

Personal 77,040 3,507 51,842 30 21,661

N/Ad1,008 5 1,003 0 0

Subtotal 13,198,206 9,797,272 3,263,281 28,691 108,962

Abdomen and pelvis

General 3,579,463 1,848,590 1,685,573 21,882 23,418

Personal 24,523 13,489 10,924 0 110

Subtotal 3,603,986 1,862,079 1,696,497 21,882 23,528

Head, neck, and chest 

General 1,907,810 1,295,574 603,117 1,853 7,266

Direct 148,023 135,164 11,784 729 346

Subtotal 2,055,833 1,430,738 614,901 2,582 7,612

Ultrasonic guidance

General 454,230 248,076 199,252 0 6,902

Personal 530,948 273,706 249,159 7 8,076

N/Ad18,042 34 16,704 0 1,304

Subtotal 1,003,220 521,816 465,115 7 16,282

Appendix II: Ultrasound Procedures and 

Medicare Part B Payments in 2005 

Page 49 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix II: Ultrasound Procedures and

Medicare Part B Payments in 2005 

Site of service

Type of ultrasound

procedure

Level of

physiciansupervision

required

Number of 

proceduresa

Physician’s 

office

Hospital 

outpatient 

department 

Skilled 

nursing 

facilityb

Other

c

Other diagnostic General 538,598 414,036 115,241 1,300 8,021

ultrasound Direct 21,220 10,857 10,051 0 312

Personal 18,959 2,661 16,113 0 185

N/Ad1,440,976 1,319,944 102,963 7,230 10,839

Subtotal 2,019,753 1,747,498 244,368 8,530 19,357

Total number of all 

procedures provided to 

beneficiaries 28,228,813 19,181,152 8,660,331 131,396 255,934

Source: GAO analysis of Medicare claims data for 2005 and Medicare regulations and policy guidance on the level of physician

supervision required for diagnostic tests. 

Notes: General supervision level means that the procedure is furnished under the physician’s overall 

direction and control, but physician presence is not required during the performance of the procedure.

This is the minimal level required for all diagnostic tests payable under the physician fee schedule, 

unless there are specific exceptions by regulation. Direct supervision means that the physician does

not have to be present in the room when the procedure is performed, but the physician must be in the 

suite and be immediately available to furnish assistance throughout the procedure. Personal 

supervision means that the physician must be in attendance in the room during the performance of 

the procedure. 

a

The number of procedures is based on claims for ultrasound exams paid and claims for ultrasound 

procedures classified solely as physician services that do not include a separately billed exam and 

physician’s interpretation of it. 

b

We counted the number of exams in skilled nursing facilities and nursing facilities.

c

Other includes (but is not limited to) home, independent laboratory, inpatient hospital, ambulatory 

surgical center, and emergency room. 

d

N/A means not applicable. 

Page 50 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix II: Ultrasound Procedures and

Medicare Part B Payments in 2005 

Table 5: Top Five Medical Conditions Diagnosed by Type of Ultrasound Procedure Provided to Medicare Beneficiaries under 

Medicare Part B, 2005 

Type of ultrasound procedure Top five medical conditions diagnosed

Number of 

procedures 

Percentage

within procedure

type

Noninvasive vascular 

Occlusion and stenosis of precerebral arteries 1,661,280 20

Other disorders of soft tissue 1,603,593 19

Atherosclerosis 737,405 9

Other peripheral vascular diseases 728,566 9

Cardiovascular system problems 541,018 6

Subtotal top five 5,271,862 63

Other noninvasive vascular 3,086,800 37

Total 8,358,662 100

Echocardiogram 

Other diseases of endocardium 5,740,723 26

Symptoms involving respiratory system and other 

chest symptoms 2,655,795 12

Other forms of chronic ischemic heart disease 2,058,896 9

Heart failure 2,054,101 9

Cardiac dysrhythmias 1,375,924 6

Subtotal top five 13,885,439 64

Other echocardiograms 7,947,756 36

Total 21,833,195 100

Abdomen and pelvis

Other symptoms involving abdomen and pelvis 1,340,438 27

Other disorders of kidney and ureter 462,420 9

Other disorders of urethra and urinary tract 263,473 5

Cholelithiasis 242,872 5

Symptoms involving urinary system 194,177 4

Subtotal top five 2,503,380 51

Other abdomen and pelvis 2,425,031 49

Total 4,928,411 100

Head, neck, and, chest 

Cataract 1,176,137 49

Other disorders of breast 386,908 16

Nontoxic nodular goiter 162,762 7

Nonspecific abnormal findings on radiological and 

other examinations of body structure 146,047 6

Page 51 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix II: Ultrasound Procedures and

Medicare Part B Payments in 2005 

Type of ultrasound procedure Top five medical conditions diagnosed

Number of 

procedures 

Percentage

within procedure

type

Benign mammary dysplasias 103,954 4

Subtotal top five 1,975,808 82

Other head, neck, chest 438,042 18

Total 2,413,850 100

Ultrasonic guidance

Malignant neoplasm of prostate 229,242 18

Nonspecific findings on examination of blood 150,046 12

Other and unspecified aftercare 120,019 10

Pleurisy 104,175 8

Other symptoms involving abdomen and pelvis 84,506 7

Subtotal top five 687,988 55

Other ultrasonic guidance 552,716 45

Total 1,240,704 100

Other diagnostic ultrasounds

Symptoms involving urinary system 836,940 40

Hyperplasia 310,658 15

Nonspecific findings on examination of blood 168,274 8

Malignant neoplasm of prostate 93,512 4

Other disorders of bladder 83120 4

Subtotal top five 1,492,504 70

All other 626,456 30

Total 2,118,960 100

Total number of procedures 

provided to Medicare 

beneficiaries 40,893,782 

Source: GAO analysis of Medicare claims data for 2005. 

Note: Percentages may not sum to 100 due to rounding. Our analysis is based on claims for 

physicians’ interpretation of the exams and claims for ultrasound procedures classified solely as

physician services that do not include a separately billed exam and physician’s interpretation of it. 

Page 52 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix II: Ultrasound Procedures and

Medicare Part B Payments in 2005 

Table 6: Top Five Medical Conditions Diagnosed by Type of Ultrasound Procedure Provided in SNFs to Medicare 

Beneficiaries in Noncovered SNF stays and Paid Under Medicare Part B, 2005 

Type of ultrasound procedure Top five medical conditions diagnosed

Number of 

procedures 

Percentage within

procedure type

Noninvasive vascular 

Other disorders of soft tissues 19,019 28

Symptoms involving skin and other 

integumentary tissue 

12,444 18

Other peripheral vascular disease 10,876 16

Phlebitis and thrombophlebitis 5,606 8

Atherosclerosis 5,239 8

Subtotal top five 53,184 78

Other noninvasive vascular 15,227 22

Total 68,411 100.00

Echocardiogram 

Heart failure 7,943 28

Other diseases of endocardium 3,763 13

Cardiac dysrhythmias 2,884 10

Symptoms involving Respiratory systems and 

other chest symptoms 

2,669 9

Diseases of mitral and aortic valves 1,623 6

Subtotal top five 18,882 66

Other echocardiograms 9,571 34

Total 28,453 100.00

Abdomen and pelvis

Other symptoms involving abdomen and pelvis 10,450 48

Other disorders of kidney and ureter 1,408 7

Nonspecific abnormal results of function 

studies 

1,314 6

Other disorders of urethra and urinary tract 1,239 6

Symptoms involving urinary system 1,081 5

Subtotal top five 15,492 72

Other abdomen and pelvis 6,145 28

Total 21,637 100.00

Page 53 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix II: Ultrasound Procedures and

Medicare Part B Payments in 2005 

Type of ultrasound procedure Top five medical conditions diagnosed

Number of 

procedures 

Percentage within

procedure type

Head, neck, and chest 

Cataract 889 35

Other disorders of breast 244 10

Other retinal disorders 218 9

Simple and unspecified goiter 174 7

Visual disturbances 120 5

Subtotal five 1,645 65

Other 905 35

Total 2,550 100.00

Ultrasonic guidance

Nonspecific findings on examination of the 

blood 

2 40

Chronic renal failure 1 20

Other disorders of soft tissue 1 20

Organ or tissue replaced by transplant 1 20

Subtotal top foura5 100.00

Other 0 0

Total 5 100.00

Other diagnostic ultrasound

Symptoms involving urinary system 5,700 71

Other disorders of bladder 676 8

Other disorders of bone and cartilage 560 7

Other disorders of male genital organs 188 2

Symptoms involving skin and integumentary

tissue 

130 2

Subtotal top five 7,254 90

Other 809 10

Total 8,063 100.00

Total number of procedures 

provided in SNFs to Medicare 

beneficiaries in noncovered SNF

stays 129,119 100.00

Source: GAO analysis of Medicare claims data for 2005. 

Note: Percentages may not sum to 100 due to rounding. Our analysis is based on claims for 

ultrasound exams and claims for ultrasound procedures classified solely as physician services that do

not include a separately billed exam and physician’s interpretation of it. 

a

There were only four medical conditions diagnosed by these five ultrasound guidance procedures. 

Page 54 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix III: Detailed Estimates of the 

Financial Impact of Changing Medicare Appendix III: Detailed Estimates of the Ultrasound Payment Methods 

Financial Impact of Changing Medicare 

Ultrasound Payment Methods 

This appendix contains information on the financial impact of paying for 

ultrasound equipment transportation. (See table 7.) In addition, this 

appendix presents information on changes in the number of ultrasound 

exams conducted in skilled nursing facilities (SNF) between 1995 and 1997 

(see table 8). 

Table 7: Financial Impact of Ultrasound Equipment Transportation Payments, 2005

Equipment transportation payment 

only

Equipment transportation and setup payments 

Site of service

Ultrasound 

exams 

(number)

Beneficiary 

daysa

(number)

Increase in

Medicare 

payments 

(dollars)

Increase in

beneficiary cost 

sharing (dollars)

Increase in

Medicare 

payments 

(dollars)

Increase in

beneficiary cost 

sharing (dollars)

Skilled nursing facilitiesb129,119 83,591 8,477,240 2,262,706 9,786,084 2,636,868

Home 101,285 36,880 3,362,665 883,980 4,408,509 1,164,498

Custodial care facilities 17,490 7,900 837,061 218,101 1,007,215 264,314

Assisted living facilities 5,297 2,724 253,723 68,711 304,903 83,795

Total 253,191 131,095 12,930,690 3,433,498 15,506,711 4,149,475

Source: GAO analysis of Medicare Part B claims data for 2005. 

Notes: Dollar amounts may not sum to totals due to rounding. To calculate the number of ultrasound 

exams, we counted the exams themselves that were paid under Part B, as well as ultrasound 

procedures classified solely as physician services that do not include a separately billed exam. 

Ultrasound exams were defined as HCPCS codes in the BETOS categories for echography in 

addition to 10 diagnostic ultrasound codes that were not in these categories. Calculations are based 

on the assumption that mobile ultrasound providers would receive a single transportation fee per 

beneficiary day. When indicated, mobile ultrasound providers also receive a single equipment set-up 

payment for each ultrasound exam. Transportation and set-up payment amounts are estimated based 

on the amount Medicare carriers paid for portable X-ray equipment transportation in the locality where 

the exam was conducted. See appendix I for more information on how we defined ultrasound exams.

a

Indicates the number of days on which ultrasound exams occurred. For example, if a given 

beneficiary received at least one ultrasound exam on 2 days, this would count as 2 beneficiary days. 

b

Based on exams conducted in either a SNF or nursing facility during a noncovered SNF stay. 

Page 55 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix III: Detailed Estimates of the 

Financial Impact of Changing Medicare 

Ultrasound Payment Methods 

Table 8: Percentage Change in Number of Ultrasound Exams in SNFs, 1995 to 1997 

Number of ultrasound exams 

1995 1997 

Percentage

change

States where Medicare provided separate payments for ultrasound 

equipment transportation in 1995a

8,365 28,170 237

States where Medicare did not provide separate payments for 

ultrasound equipment transportation in 1995a

23,281 37,708 62

Source: GAO analysis of Medicare Part B claims data for 1995 and 1997 from the Part B Extract Summary System. 

Note: Ultrasound exams that were conducted in a SNF or nursing facility were defined as HCPCS 

codes in the BETOS categories for echography. 

a

Beginning in 1996, there were not any states with carriers that provided separate payments for 

ultrasound equipment transportation, but carriers in the following states did so in 1995: Arizona, 

California (Northern), Connecticut, Delaware, Georgia, Iowa, Maine, Maryland, Massachusetts, 

Missouri, Nevada, New Hampshire, New Jersey, Pennsylvania, and Vermont. We excluded California

from our analysis because the policy on payments for ultrasound equipment transportation and set up 

was not consistent throughout the state. 

Page 56 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix IV: Studies on Accreditation of

Facilities and the Credentialing of 

Sonographers 

Author/title Objective(s) of study Study methods Study results 

David G. Stanley, “The 

Importance of Intersocietal 

Commission for the 

Accreditation of Vascular 

Laboratories (ICAVL) 

Certification for Noninvasive 

Peripheral Vascular Tests: The 

Tennessee Experience,” The 

Journal for Vascular 

Ultrasound, vol. 28, no. 2 

(2004). 

To determine the accuracy of 

noninvasive vascular 

ultrasound procedures 

conducted by accredited and 

nonaccredited facilities. 

The study compared the results 

of noninvasive vascular 

ultrasound procedures 

performed by an accredited 

facility to the results of studies

that were initially performed by

both accredited and 

nonaccredited facilities. The 

study reviewed a total of 437 

ultrasound carotid duplex 

exams.a

 

The study found an 83 percent

correlation rate for ultrasound 

procedures that were initially 

performed at accredited facilities. 

However, when the initial study 

was performed by a 

nonaccredited facility, the 

correlation rate for reviewed

studies was 45 percent. 

Alfred Z. Abuhamad et al., “The 

Accreditation of Ultrasound 

Practices Impact on 

Compliance with Minimum 

Performance Guidelines,” 

Journal of Ultrasound in 

Medicine, vol. 23, no. 8 (2004). 

To determine the effectiveness 

of the American Institute of 

Ultrasound in Medicine (AIUM) 

accreditation program in 

improving compliance with

standards and guidelines for 

the performance of obstetric 

and gynecologic ultrasound 

examinations.b

The scores of case studies in

82 AIUM accreditation 

applications were compared 

with their respective scores at 

the time of reaccreditation 

3 years later. To account for 

the element of time, scores of 

applications that recently 

completed first-time 

accreditation were also 

compared as a control group.

The study found that practices

that applied for, and were granted, 

ultrasound accreditation were able 

to improve the scores of case 

studies and to achieve 

compliance with AIUM minimum 

standards and guidelines for the 

performance of gynecologic and 

obstetric ultrasound examinations. 

The study concluded that the 

improvement in scores should

translate into an enhancement of 

the quality of the ultrasound 

practice. 

O. William Brown, et al., 

“Reliability of Extracranial 

Carotid Artery Duplex 

Ultrasound Scanning: Value of 

Vascular Laboratory 

Accreditation,” Journal of 

Vascular Surgery, vol. 39, no. 2 

(2004). 

To evaluate the reliability of 

carotid duplex ultrasound 

scanning procedures 

performed by nonaccredited

vascular laboratories and to 

assess the clinical effect on 

patient management.a

The study compared the quality 

and reliability of carotid duplex

ultrasound scanning 

procedures performed by a 

nonaccredited vascular 

laboratory with repeat 

examinations performed in the

Beaumont laboratory, which is

accredited by the Intersocietal

Commission for Accreditation 

of Vascular Laboratories. 

The study found that of the 174 

patients referred for surgical

evaluation for carotid 

endarterectomy,c

 88 of these 

patients did not have the severe 

or critical carotid stenosis 

(narrowing) that had been 

diagnosed initially. Since these 

patients had all been referred for 

carotid endarterectomy, 

unnecessary and potentially 

dangerous operations were 

avoided when the accredited 

laboratory disproved the false

positive results from the 

nonaccredited facilities. For an

additional 19 patients, the disease 

severity had been significantly

underestimated by the 

nonaccredited laboratories. 

Appendix IV: Studies on Accreditation of 

Facilities and the Credentialing of 

Sonographers 

Page 57 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix IV: Studies on Accreditation of

Facilities and the Credentialing of 

Sonographers 

Author/title Objective(s) of study Study methods Study results 

S. Boswell et al., “Practice 

Patterns and Membership 

Opinion About the Value of 

Credentialing and 

Accreditation: Results of a 

Membership Survey,” Journal 

of Diagnostic Medical

Sonography, vol. 19, no. 6 

(2003). 

To evaluate the opinions of 

vascular technologists and 

sonographers who routinely 

perform vascular procedures 

about the value of credentialing 

and accreditation and to 

assess their current practice 

patterns for the performance of

carotid duplex ultrasound 

procedures. 

Researchers surveyed 100 

members of the Society of 

Diagnostic Medical Sonography 

and the Society for Vascular 

Ultrasound in Kentucky and 

Indiana. There was a 

30 percent response rate. 

The study found that 12 percent of 

(4,782) carotid duplex procedures 

considered in the study were

repeated annually. 

Among the reasons cited by 

respondents for repeat tests was 

that the sonographers conducting 

the exams were not sufficiently

competent. 

Respondents noted that the 

original procedures often showed 

a lack of basic sonography 

knowledge, resulting in poor 

quality images. 

Source: GAO based on sources cited above.

a

A duplex ultrasound scan is a noninvasive diagnostic ultrasound procedure that uses color Doppler 

technology to provide information about blood flow and the condition of the arteries and veins. This 

test is typically used to diagnose suspected artery disease and other vascular problems, including 

blockage in the carotid artery in the neck. 

b

The AIUM provides accreditation for practices rather than individuals. As one step in the process, 

practices applying for accreditation must submit four case studies for each specified area of 

accreditation (obstetrics, gynecology, breast, and abdomen). These case studies are scored by 

independent reviewers according to established criteria that conform to the minimum standards and

guidelines for ultrasound practices as developed by the AIUM. 

c

Endarterectomy is the general term for the surgical removal of plaque from an artery that has 

become narrowed or blocked. To perform an endarterectomy, the physician makes an incision in the 

affected artery and removes the plaque contained in the artery’s inner lining. This procedure opens 

the artery and restores blood flow. Physicians use endarterectomy to treat many arteries; however, 

the most common use is for carotid arteries, which are in the neck and deliver blood to the brain. 

Page 58 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix V: Information about Groups That 

Support Ultrasound Credentialing and 

Accreditation Requirements 

Group Information on group

The American College of Radiology The American College of Radiology is a nonprofit, professional association that 

represents 30,000 diagnostic radiologists, radiation oncologists, interventional 

radiologists, nuclear medicine physicians, and medical physicists. The organization’s 

ultrasound accreditation program was established in 1995, and it includes general 

ultrasound, obstetrics, gynecological, and vascular ultrasound. This accreditation program 

requires that all sonographers be certified. 

The American Society of 

Echocardiography 

The American Society of Echocardiography is a professional organization of physicians, 

cardiac sonographers, nurses, and scientists involved in echocardiography, which is the 

use of ultrasound to image the heart and cardiovascular system. The organization was 

founded in 1975 and has more than 10,000 members nationally and internationally. 

American Institute of Ultrasound in 

Medicine 

The American Institute of Ultrasound in Medicine is a multidisciplinary organization that 

was officially established in 1952. The organization supports professional and public 

education, research, development of guidelines, and accreditation. The organization’s 

ultrasound practice accreditation council has developed standards for the accreditation of

ultrasound practices. 

American Registry for Diagnostic Medical 

Sonography 

The American Registry for Diagnostic Medical Sonography is an independent nonprofit 

organization that, for 29 years, has awarded credentials to ultrasound professionals 

through examinations. The organization offers certification in three ultrasound clinical 

specialties: Registered Diagnostic Medical Sonographer, Registered Diagnostic Cardiac 

Sonographer, and Registered Vascular Technologist. The organization has over 44,000 

actively certified ultrasound professionals. 

Cardiovascular Credentialing International Cardiovascular Credentialing International is an independent nonprofit organization that 

awards credentials to vascular technology professionals through credentialing 

examinations. The organization administers credentials in four cardiovascular technology

specialties: Certified Cardiographic Technician, Registered Cardiovascular Invasive 

Specialist, Registered Cardiac Sonographer, and Registered Vascular Specialist. 

Intersocietal Commission for the 

Accreditation of Echocardiography 

Laboratories 

The Intersocietal Commission for the Accreditation of Echocardiography Laboratories has 

been in operation since 1996 and currently has accredited over 900 echocardiography 

laboratories in the United States and Canada. The commission provides a laboratory 

peer-review evaluation program for echocardiography procedures. 

Intersocietal Commission for the 

Accreditation of Vascular Laboratories 

The Intersocietal Commission for the Accreditation of Vascular Laboratories has been in 

operation since 1991 and currently has over 1,400 accredited laboratories in the United

States and Canada. The organization provides a peer-review process of laboratory 

accreditation for noninvasive vascular diagnostic testing. 

Joint Review Committee on Education in 

Diagnostic Medical Sonography 

Founded in 1979, the Joint Review Committee on Education in Diagnostic Medical 

Sonography is the only nationally recognized organization that accredits diagnostic 

medical sonography programs. The primary purpose of the organization is to establish, 

maintain, and promote appropriate standards of quality for educational programs in 

diagnostic medical sonography and to provide recognition for educational programs that 

meet or exceed these standards. 

Society of Diagnostic Medical Sonography The Society of Diagnostic Medical Sonography is a professional membership organization

founded in 1970 to promote, advance, and educate its members and the medical

community in the science of diagnostic medical sonography. The organization has over 

17,000 members and is the largest association of sonographers and sonography students 

in the world. 

Appendix V: Information about Groups That 

Support Ultrasound Credentialing and 

Accreditation Requirements 

Page 59 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix V: Information about Groups That 

Support Ultrasound Credentialing and 

Accreditation Requirements 

Group Information on group

Society for Vascular Surgery The Society for Vascular Surgery is the oldest and largest national association of vascular

surgeons in the United States. It was founded in 1947 and merged with the American 

Association for Vascular Surgery in 2003. The Society has a membership of more than 

2,200 vascular surgeons. Society members serve on the boards of major vascular 

sonographer associations as well as the major ultrasound credentialing and accrediting 

organizations. 

Society for Vascular Ultrasound The Society for Vascular Ultrasound is the only national professional organization 

dedicated exclusively to the advancement of noninvasive vascular technology used for 

diagnostic purposes. The organization’s membership is comprised of more than 4,100 

registered vascular technologists, sonographers, nurses, and physicians. 

Sources: GAO interviews and analysis of information presented in the letter from the Coalition for Quality in Ultrasound to MedPAC,

September 3, 2004, and groups’ Web sites concerning their history, mission, and membership, including Who’s Who in Sonography,

Membership Associations, http://www.sdms.org/about/who.asp, downloaded October 23, 2006. 

Page 60 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix VI: Comments from the Centers for Appendix VI: Comments from the Centers for Medicare & Medicaid Services 

Medicare & Medicaid Services 

Page 61 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 62 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 63 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix VI: Comments from the Centers for 

Medicare & Medicaid Services 

Page 64 GAO-07-734 Medicare Diagnostic Ultrasound Services
Appendix VII: GAO Contact and Staff Acknowledgments 

Page 65 GAO-07-734

Appendix VII: GAO Contact and Staff 

Acknowledgments 

A. Bruce Steinwald (202) 512-7114 or steinwalda@gao.gov

In addition to the contact named above, Sheila K. Avruch, Assistant 

Director; Jennie Apter; William Black; Kevin Dietz; Sandra Gove; and 

Carmen Rivera-Lowitt made key contributions to this report. 

Medicare Diagnostic Ultrasound Services

GAO Contact 

Acknowledgments 

(290557) 
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