Original article
Dramatically Increased Musculoskeletal Ultrasound Utilization From 2000 to 2009, Especially by Podiatrists in Private Offices

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Purpose

Over the past two decades, musculoskeletal (MSK) ultrasound has emerged as an effective means of diagnosing MSK pathologies. However, some insurance providers have expressed concern about increased MSK ultrasound utilization, possibly facilitated by the low cost and ready availability of ultrasound technology. The purpose of this study was to document trends in MSK ultrasound utilization from 2000 to 2009 within the Medicare population.

Methods

Source data were obtained from the CMS Physician/Supplier Procedure Summary Master Files from 2000 to 2009, and records were extracted for procedures for extremity nonvascular ultrasound. We analyzed annual volume by provider type using specialties, practice settings, and geographic regions where the studies were performed.

Results

In 2000, Medicare reimbursed 56,254 MSK ultrasound studies, which increased to 233,964 in 2009 (+316%). Radiologists performed the largest number of MSK ultrasound studies in 2009, 91,022, an increase from 40,877 in 2000. Podiatrists utilized the next highest number of studies in 2009, 76,332, an increase from 3,920 in 2000. Overall, private office MSK ultrasound procedures increased from 19,372 in 2000 to 158,351 in 2009 (+717%). In 2009, podiatrists performed the largest number of private office procedures (75,544) and accounted for 51.5% of the total private office growth from 2000 to 2009. Radiologist private office procedures totaled 19,894 in 2009, accounting for 9.2% of the total private office MSK ultrasound growth.

Conclusions

The MSK ultrasound volume increase among nonradiologists, especially podiatrists, was far higher than that among radiologists from 2000 and 2009, with the highest growth in private offices. These findings raise concern for self-referral.

Introduction

Policymakers, health care payers, health care providers, and patients are increasingly aware of the cost of providing health care in the United States. Medical imaging is one of the main drivers of increasing health care costs [1]. For musculoskeletal (MSK) imaging, Parker et al [2] demonstrated that MSK ultrasound is relatively underutilized in the United States and that substituting ultrasound for MRI in specific clinical scenarios could substantially reduce imaging costs. Paradoxically, insurers have recently raised concerns of MSK ultrasound overutilization [3]. In particular, the wide availability and relatively low cost of ultrasound technology have led to widespread proliferation of ultrasound units and potential for overutilization.

The purpose of this study was to examine MSK ultrasound used for the diagnosis of tendon, muscle, ligament, nerve, and joint abnormalities; we do not address studies performed for ultrasound-guided intervention. We investigated which types of health care providers in what settings utilize diagnostic MSK ultrasound, their relative utilization frequencies, and geographic variations.

Section snippets

Methods

The source data sets were the CMS Part B Physician/Supplier Procedure Summary Master Files (PSPSMFs) for 2000 through 2009. This data set summarizes the complete billing record for all procedures paid under Medicare Part B. For every Current Procedural Terminology®, fourth ed (CPT®-4), code in each year, the PSPSMFs provide the volume of services performed nationwide. There were 32,823,781 fee-for-service beneficiaries enrolled in Medicare Part B in 2000 and 34,937,790 in 2009, with a peak

Results

Musculoskeletal ultrasound volume increased from 56,254 procedures in 2000 to 233,964 in 2009 (+316%). The total utilization rate of MSK ultrasound was 171 per 100,000 in 2000 and 669 per 100,000 in 2009 (+291%).

Figure 1 shows that MSK ultrasound procedure volume varied by provider type. The largest number of MSK ultrasound procedures in every year from 2000 to 2009 was performed by radiologists who performed 40,877 procedures in 2000 and 91,022 in 2009 (+123%). Radiologists' volume accounted

Discussion

The US Government Accountability Office (GAO) [1] stated that from 2000 to 2006, spending for medical imaging more than doubled, to $14 billion. The GAO has also reported that from 2000 through 2006, Medicare spending for physician imaging services doubled from about $7 billion to about $14 billion, an average annual increase of 13%, compared with an 8% increase in spending for all Medicare physician-billed services over the same time period [4]. The GAO further concluded that there was

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