PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2013 COUNCIL MEETING. RESOLUTIONS ARE NOT
OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE).
RESOLUTION:
33(13)
SUBMITTED BY:
Emergency Ultrasound Section
New York Chapter
North Carolina College of Emergency Physicians
SUBJECT:
Clinical Ultrasound is a Specific Imaging Modality
PURPOSE: Define clinical ultrasonography as a diagnostic modality that provides clinically important data not
obtainable by inspection, palpation, auscultation or other components of a physical exam and to recognize clinical
ultrasonography as a unique clinical modality, separate from the physical examination.
FISCAL IMPACT: Staff labor for dissemination and promotion of information regarding the use of clinical
ultrasound by emergency physicians.
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WHEREAS, Clinical Ultrasonography is a recognized multi-specialty modality that is used to diagnose,
treat, monitor, resuscitate and provide procedural guidance1,2; and
WHEREAS, Clinical Ultrasonography, while applicable at the bedside, is not an extension of or adjunct
to the physical examination; and
WHEREAS, Clinical Ultrasonography requires unique knowledge and expertise, equipment, supplies,
technical, procedural, interpretive, and integrative skills unique and separate from the physical examination; and
WHEREAS, Clinical Ultrasonography, while routinely performed in conjunction with or immediately
following the physical exam, is a distinctly separate procedure; and
WHEREAS, Clinical Ultrasonography is integral and contemporaneous in medical decision making
during the patient encounter; and
WHEREAS, Clinical Ultrasonography is documented in the medical record with generation of a report
including indications, findings, and interpretation; therefore be it
RESOLVED, That ACEP define Clinical Ultrasonography as a diagnostic modality; and be it further
RESOLVED, That ACEP recognizes that Clinical Ultrasonography provides clinically important data not
obtainable by inspection, palpation, auscultation, or other components of the physical exam; and be it further
RESOLVED, That ACEP recognize Clinical Ultrasonography as a unique clinical modality, separate
from the physical examination, and not “an adjunct to or extension of the physical examination.”
References
1
American Medical Association. Resolution H-230.960: Privileging for Ultrasound Imaging. Chicago, IL: American Medical
Association; 1999. Resolution 802, page 480
2
Eurle B, Butler K. Diagnostic ultrasonography in emergency medicine. Critical Decisions In Emergency Medicine. 2004;
18:1-8.
Resolution 33(13) Clinical Ultrasound
Page 2
Background
This resolution calls for the College to define clinical ultrasonography as a diagnostic modality that provides
clinically important data not obtainable by inspection, palpation, auscultation or other components of a physical
exam and to recognize clinical ultrasonography as a unique clinical modality, separate from the physical
examination.
The clinical use of emergency ultrasound has expanded greatly since its original application in emergency
medicine decades ago. Clinical ultrasound is used to diagnose acute life-threatening conditions, guide invasive
procedures and treat emergency medical conditions. ACEP has a lengthy history of supporting clinical ultrasound
(also referred to as emergency ultrasound or bedside ultrasound) as a distinct and separate modality apart from the
physical examination.
In 1999 ACEP was instrumental in presenting a resolution to the American Medical Association (AMA)
“Regarding Privileging for Ultrasound Imaging.” The AMA H-230.960 policy “Privileging for Ultrasound
Imaging” (reaffirmed in 2010) states in part that “AMA affirms that ultrasound imaging is within the scope of
practice of appropriately trained physicians.”
The ACEP Board approved the policy “Emergency Ultrasound Imaging Criteria Compendium” in 2006. This
policy was developed to assist practitioners performing emergency ultrasound and contains the following criteria:
aorta, biliary, echocardiography, pelvic ultrasound, renal, trauma, venous thrombosis and ultrasound guided
procedures.
ACEP originally approved an “Emergency Ultrasound Guidelines” policy in 2001 and approved the updated and
revised policy statement in 2008. This policy statement notes that clinical ultrasound is a core skill taught in
residency programs and that fellowships in clinical ultrasound are becoming more widely available. Most
importantly it states, “Emergency ultrasound is complimentary to the physical examination but should be
considered a separate entity” that adds anatomic, functional, and physiologic information to the care of the
emergency patient.”
The “Emergency Ultrasound Guidelines” require emergency physicians to become knowledgeable in the
indications for ultrasound applications, competent in image acquisition and interpretation, and capable of
integrating the findings appropriately in the clinical management of their patients.
As ultrasound became more widely used in the emergency department (ED) manufacturers began making
equipment more conducive (smaller, more portable) to use in the ED. As the machines became smaller other
imaging specialists proposed to insurers and other third party payers that these smaller machines were simply an
extension of the stethoscope and as a result should be considered an extension of the physical exam and therefore,
should not be a reimbursable service.
ACEP continues to refute the contention that clinical ultrasound is not a separate and unique service. As recently
as July 2013 in a letter to an imaging society, the College stated that “technology is dynamic and continuously
evolving, we believe it is neither appropriate nor will it achieve the desired result for any organization to focus on
the size of the ultrasound equipment as reason for well-trained and qualified users of ultrasound to be prevented
from performing and being reimbursed” for a clinical ultrasound exam. Current Procedural Terminology (CPT)
criteria clearly states that reimbursement should be based on the indication to perform the scan, image retention,
and report generation.
The Emergency Ultrasound Section is exploring with the AMA Section Council on Emergency Medicine the
development and submission of a resolution to the AMA to clearly state that clinical ultrasonography is a unique
clinical modality, is not part of the physical exam and that the use of clinical ultrasound should never be referred
to as an “extension of the stethoscope.”
Resolution 33(13) Clinical Ultrasound
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ACEP Strategic Plan Reference
Goal 1 – Reform and Improve the Delivery System for Emergency Care
Objective C – Pursue strategies for insuring fair payment and practice sustainability.
Fiscal Impact
Staff labor for dissemination and promotion of information regarding the use of clinical ultrasound by emergency
physicians.
Prior Council Action
Resolution 21(09) Opposition to Credentialing, Certification, or ‘Signing Off’ Processes by Other Specialties for
Core Skills Within the Scope of Practice of Emergency Medicine adopted. Directed ACEP to cooperate with all
established College liaisons and relationships with other medical specialty societies, the American Medical
Association, the Alliance for Specialty Medicine, the Coalition for Patient-Centric Imaging, and other interested
parties to actively and fully oppose the imposition upon the specialty of emergency medicine of a requirement of
any credentialing, certification, or “signing-off” process by other specialties for any core skill within the scope of
practice of emergency medicine.” – adopted.
Resolution 32(07) Emergency Ultrasound Credentialing adopted. Called for the College to work with other
organizations to oppose the imposition of non-emergency medicine formulated accreditation or certification of
emergency physician use of emergency ultrasound and to develop a strategic plan to address accreditation and
certification issues relating to the performance and interpretation of imaging studies by emergency physicians.
Resolution 51(05) Emergency Physician Autonomy in the Performance and Interpretation of Diagnostic Imaging
Studies adopted. Called for the College to work with the house of medicine and other certification and standard
setting bodies to reaffirm and promote appropriate training and educations standards for all physicians who
perform and interpret diagnostic imaging and to oppose any MedPac recommendation that would limit any
physician other than a radiologist to provide diagnostic imaging.
Substitute Resolution 45(05) Availability of Hospital Diagnostic and Therapeutic Services adopted. Directed
ACEP to promote policies that endorse consistent 7-days a week availability of hospital diagnostic and
therapeutic services to facilitate timely disposition of ED patients and minimize hospital crowding.
Amended Resolution 10(99) Ultrasound Imaging adopted. Directed ACEP to affirm ultrasound imaging is within
the scope of practice of appropriately trained physician specialists; to state that ACEP policy on ultrasound
acknowledge that broad and diverse use and application of ultrasound imaging technologies does exist in medical
practice; that ACEP policy on ultrasound imaging affirm that privileging of the physician to perform ultrasound
imaging procedures in a hospital setting should be a function of hospital medical staff and should be specifically
delineated on the Department’s Delineation of Privileges form; that ACEP policy on ultrasound imaging state that
each hospital medical staff should review and approve criteria for granting ultrasound privileges based upon
background and training for the use of ultrasound technology and ensure that these criteria are in accordance with
recommended training and education standards developed by each physician's respective specialty society; that
ACEP through its AMA delegation and other vehicles, promote this policy to other medical specialty societies,
the AMA House of Delegates, and other appropriate entities.
Amended Resolution 13(98) Ultrasound Imaging by Emergency Physicians adopted. Directed ACEP to develop
and implement a verification of training program and model credentialing standards for emergency ultrasound
imaging skills in conjunction with the ACEP Ultrasound Section of Membership; that such a verification of
training program for emergency medicine ultrasound imaging be developed to a level which can serve to assist
emergency physicians in obtaining clinical privileges in ultrasound imaging for emergency department use.
Resolution 47(96) Ultrasound Imaging adopted. Directed ACEP to create a new policy on emergency
ultrasonography to continue the tenets of the 1991 policy; affirm that limited bedside ultrasound imaging is within
Resolution 33(13) Clinical Ultrasound
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the scope of practice of emergency physicians; support ultrasound use by emergency physicians for at least the
detection of suspected traumatic hemoperitoneum, abdominal aortic aneurysm, pericardial effusion, and ectopic
pregnancy; and that ACEP work with other interested organizations to examine curriculum, training, and
credentialing issues in the use of limited ultrasound imaging by emergency physicians.
Amended Substitute Resolution 42(90) Ultrasound adopted. Directed the College to support and encourage the
immediate availability of ultrasound technology for emergency department patients by appropriately trained and
credentialed physicians, including emergency physicians; develop guidelines by which an emergency physician
would be considered to be appropriately trained; and work with third-party payers to insure that emergency
physicians receive fair and appropriate reimbursement for providing ultrasound diagnostic services in emergency
facilities.
Prior Board Action
February 2013, approved policy statement “Interpretation of Imaging Diagnostic Studies.” Originally approved
March 1990; reaffirmed and approved October 2000; revised and approved September 1996 and June 2006.
Resolution 21(09) Opposition to Credentialing, Certification, or ‘Signing Off’ Processes by Other Specialties for
Core Skills Within the Scope of Practice of Emergency Medicine adopted.
October 2008, approved policy statement “Emergency Ultrasound Guidelines.” Originally approved June 2001.
Resolution 32(07) Emergency Ultrasound Credentialing adopted.
April 2006, approved policy statement “Emergency Ultrasound Imaging Criteria Compendium.”
Resolution 51(05) Emergency Physician Autonomy in the Performance and Interpretation of Diagnostic Imaging
Studies adopted.
Resolution 45(05) Availability of Hospital Diagnostic and Therapeutic Services adopted.
Resolution 10(99) Ultrasound Imaging adopted.
Resolution 13(98) Ultrasound Imaging by Emergency Physicians adopted.
Resolution 47(96) Ultrasound Imaging adopted.
Amended Resolution 42(90) Ultrasound adopted.
Background Information Prepared By: Marilyn Bromley, RN
Emergency Medicine Practice Director
Reviewed By: Marco Coppola, DO, FACEP, Speaker
Kevin Klauer, DO, EJD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director