POCUS reimbursement & the ROI calculator.
You might be fully convinced of the point-of-care ultrasound (POCUS) benefits on patient care, but is your boss on board with it? The quickest way to get administrators’ support is to show an intervention that improves quality AND brings in revenue. Fortunately, POCUS does both things. In this post, we will explore some of the intricacies of POCUS reimbursement and introduce the POCUS ROI Calculator.
Professional, Technical vs. Global Fees
POCUS CPT codes are comprised of professional and technical components.
The professional component of a diagnostic service/procedure is provided by the physician, and may include supervision, interpretation, and a written report.
The technical component of a diagnostic service/procedure accounts for equipment, supplies, and clinical staff (such as technicians). Payment for the technical component also includes the practice expense and the malpractice expense.
For example, if you are part of a physician group that practices within a hospital, you can bill for professional fees only (modifier -26), while the hospital will bill for the technical fees (modifier -TC). However, if you are part of an independent primary care practice, you can bill for global fees as you not only performed the exam, but your practice also acquired, maintains, and hosts the machines in a physical space.
In general, technical fees are 1/2 to 2/3 of global fees, but there are exceptions. For example, limited cardiac exam (CPT93308) carries global Medicare fee of approximately $100, with technical component at $75 and professional component at $25. On the other hand, limited soft tissue or musculoskeletal exam (CPT 76882) has global Medicare fee of $43, with technical and professional components being $10 and $33, respectively. See Tables 1 & 2 for a more comprehensive lists of reimbursements by CPT code.
Table 1: 2023 Medicare Fees for Common POCUS Diagnostic Exams
Table 2: 2023 Medicare Fees for Common Ultrasound-Guided Procedures
Why bill for POCUS
No matter what type of setting you practice in, POCUS is a billable procedure as long as it is performed by a credentialed individual, archived, and documented. Billing for POCUS not only brings funds to pay for POCUS device, infrastructure, provider training, but it also provides administration with the POCUS utilization data. The more POCUS you do to enhance patient care, the more support the POCUS program will get from the administration. And the best way to show it, in addition to showing better patient outcomes and experience, is to bill for POCUS exams performed.
Is there really money in this?
There are numerous studies showing the benefits of POCUS on patient care. It increases diagnostic certainty and ED throughput, decreased complications of certain procedures, and enhances patient experience. Those are the main reasons why facilities should offer POCUS to their patients! However, POCUS also comes with a perk. It's a billable exam that could bring additional $15-30K to a small primary care practice annually and up to $1 mil per year to an ED with a robust POCUS program.
POCUS by mid-level providers
Many mid-level providers have training and perform POCUS to enhance patient care. In general, they can bill at 85% of physician fees. Make sure to stay compliant with your state and facility regulations on mid-level provider supervision prior to billing for POCUS.
Medicare vs. Medicaid vs. Private Insurers
Medicare sets the fees each year. You can search the fees by CPT code here. Medicaid pays roughly 70% of Medicare fees according to this report by Medicare Payment Advisory Commission. Private insurers pay 118-163% of Medicare fees as per Congressional Budget Office analysis. Therefore, the reimbursement for POCUS exam will depend on your patient payer mix and on the agreements your facility has with various commercial insurances.
The POCUS ROI calculator
If you are curious to see what kind of revenue is possible with POCUS, check out our POCUS ROI calculator. This calculator estimates monthly and annual POCUS ROI based on the global fees for various POCUS exam types and the payer mix. Use this tool to convince your administration to get a POCUS program started at your facility!
Other ways POCUS improves revenue
Direct billing is only one of the ways POCUS brings revenue. Depending on your payer agreements, using POCUS to increase complexity of patient visit instead of direct billing might be financially beneficial. In the past one could do both, but as of 2023 one must choose whether to bill for POCUS or use it toward increasing complexity of the visit.
Furthermore, POCUS has been shown to decrease complications of procedures and length of stay, while enhancing patient care and experience. There is a considerable ripple effect from this. Decreased complication rate and higher throughput could help a facility meet quality measures, that in turn improve Medicare reimbursement. Less complications also lead to less malpractice cases. Imagine all the millions of dollars saved! Meanwhile, better patient experience leads to higher ratings and more referrals.
Summary
The bottom line is that POCUS is a billable, and it pays for itself. A robust POCUS program can easily generate additional revenue for the practice. Use our POCUS ROI calculator to estimate the POCUS revenue you might be leaving on the table.