ICAVL, Credentialing and Reimbursement

Credentialing in ultrasound had its foundation in the concept of the performance of quality (and, therefore, accurate) ultrasound and the desire by those who specialized in ultrasound to demonstrate competence in their chosen profession. This started out as a voluntary effort by those early pioneers committed to quality patient diagnosis, having chosen an honorable profession of working in healthcare. An interesting factoid: The very first registered radiographic technologist was Sister M. Beatrice Merrigan, who became registered in 1922 through the American College of Radiology. Imaging technologies have certainly come a long way since that time. In the latter part of the 20th century, we had the development of several ultrasound organizations focused on education. Examples include, but are not limited to, the Society for Vascular Ultrasound, Society of Diagnostic Medical Sonographers, and the American Institute of Ultrasound in Medicine. Over time, the goal of credentialing persons (and/or facilities) performing imaging studies developed, as did groups such as Cardiovascular Credentialing International (CCI ) which was formed in 1968, the American Registry of Diagnostic Medical Sonographers (ARDM S) which formed in 1975, and the Intersocietal Accreditation Commission (vascular division) which formed in 1990. The focus of this article will be on aspects of vascular ultrasound credentialing.

Credentialing for Performance or Interpretation?

When it comes to accreditation, there are 2 types: one for the individual and one for the facility. For the individual, there are credentials for either the performance or interpretation of noninvasive diagnostic vascular ultrasound. From a performance perspective, either a sonographer or a physician can achieve certification. While from an interpretation perspective, physicians are exclusively offered the ability to achieve the Registered Physician in Vascular Interpretation (RPVI ). The RPVI was “developed in response to requests from physicians in the vascular surgery and in vascular medicine communities, documents the highest standard in vascular ultrasound interpretatio…validates the clinical expertise fundamental to vascular sonography interpretation, and recognizes the skills and knowledge required for making consistent and reliable diagnoses in vascular disease.”1 The importance and significance of this credential is moving from a voluntary to mandatory status, at least in the eyes of the Vascular Surgery Board of the American Board of Surgery (VSB-ABS), who will require any vascular surgeon sitting for board examinations by 2014 to achieve the RPVI as part of the application process starting in 2014. Credentialing for the Individual For performance studies, the individual has a few options. First, it should be stated that many physician advocates have achieved performance credentials. It is commonly thought, however, that performance certification is primarily for sonographers, especially since the development of the RPVI credential. Testing of the individual is done primarily by two organizations:

• American Registry of Diagnostic Medical Sonographers (ARDMS), which was formed in 1975. ARDMS “promotes quality care and patient safety through the certification and continuing competency of ultrasound professionals.”
• Cardiovascular Credentialing International (CCI) which was established for the purpose of administering credentialing examinations as an independent credentialing agency in 1968 through high quality competency based examinations.

Both of these organizations have achieved The ANSI/ISO/IEC 17024 accreditation for their testing procedures, meeting rigorous, internationally recognized accreditation standards and representing the best practices in accreditation. The chart below details the credentials offered by organization below:

ARDMS

Registered Vascular Technologist (RVT),
Registered Physician in Vascular Interpretation (RPVI)
www.ardms.org

CCI

Registered Vascular Specialist (RVS)
Registered Phlebology Sonographer (RPhS)
www.cci-online.org

ACR

Radiographic Tech with vascular specialty (RT -VS)2
www.acr.org

The RVT and the RV S credentials are considered equivalent and are based on testing areas that include Extracranial, Cerebrovascular, Intracranial Cerebrovascular, Peripheral Arterial, Peripheral Venous, and Visceral Vascular (abdominal). The RPhS exam, relatively new, was developed by CCI in conjunction with subject matter experts in 2010 for those persons whose focus is solely on the venous system, specifically for chronic venous disease and chronic venous insufficiency (CVD and CVI ), and is recommended for sonographers and physicians alike. The RPhS credential has been endorsed by the American College of Phlebology. Furthermore, the American Board of Phlebology (ABPh) advocates the RPhS (or other vascular sonography credentials) for all of its applicants.

Prerequisites for these exams, either interpretation (RPVI ) or performance (RVT , RV S, RPhS), vary based on background and training and are clearly delineated on the websites of each organization. Over the past 20 to 30 years and with the advancement of the field, accredited two- and four-year ultrasound college programs have developed. New breeds of college-educated sonographers are graduating with more formal training both in the classroom and through clinical rotations. This has prompted some early discussion by the credentialing organizations regarding “sunsetting,” the historic “on the job” pathway for the credentialing process. Although these conversations are preliminary, indications are such that this movement will become formalized in the future.

Credentialing for the Facility

Facility credentialing is another flavor of credentials that are available. The Intersocietal Accreditation Commission (IAC) is the credentialing organization for vascular laboratory accreditation. 2 The credential was developed “to ensure high quality patient care and to promote health care by providing a mechanism to encourage and recognize the provision of quality vascular diagnostic evaluations by a process of accreditation.” 3 Furthermore, this credential can be used in marketing proficiency and competency to other healthcare professionals, and to the public at large. Although the focus of this article is the vascular laboratory, the IAC also offersaccreditation programs in Echocardiography (ICAE L), Nuclear/PET (ICAN L), MRI (ICAMR L), CT (ICACT L) and Carotid Stenting (ICAC SF).

Vascular Testing accreditation by the IAC is offered in the following testing areas:

• Extracranial Cerebrovascular
• Intracranial Cerebrovascular
• Peripheral Arterial
• Peripheral Venous
• Visceral Vascular
• Screening

Credentialing can be sought in any one or combination of these testing areas. For phlebology, venous laboratory accreditation would be the obvious choice. As a side note, there is now recognition of something new, a “Phlebology Facility” program, which is currently in the earliest stage of development. The Phlebology Facility program will likely parallel the Carotid Stenting facility accreditation program. Participating key medical societies are slated to have the Phlebology Facility board meeting in June of 2012 for the process of program development. Specifics for the acquisition of vascular lab accreditation are best viewed at the IAC website; however, it should be noted that the ICAV L Board of Directors voted unanimously to require all technical staff to hold a valid vascular credential by January 1, 2017.

Reimbursement is linked to credentialing

With all these “credentials” available, the question most people are asking is why, and which one is right for me? From a practical perspective, the why is pretty straight forward, as there have become direct links to insurance reimbursement. Medicare has recognized that the “accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill and experience of the technologist and the physician performing the interpretation of the study.”5 Furthermore, Medicare indicates that "all non-invasive vascular diagnostic studies must be performed by, or under direct supervision of, persons that have demonstrated minimum entry level competency by being credentialed in vascular technology. An example of appropriate certification includes the Registered Vascular Specialist (RV S) and the Registered Vascular Technologist (RVT ) credential. Direct supervision requires the credentialed individual's physical presence in the facility.” Clearly, Medicare has indicated the requirement for persons performing studies. It should be noted that Medicare rulings are done on a local level and posted as Local Carrier Determinations (LCD s).6

Medicare also indicates vascular laboratory accreditation as another method to meet payment criteria. “Appropriate nationally recognized laboratory accreditation bodies” include: Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAV L) and the American College of Radiology (ACR ). Directly from the IAC s website, we see the following, “In numerous states, reimbursement directives that require accreditation of the laboratory have been instituted by Medicare carriers as well as private third-party insurer. Similar draft payment policies are pending throughout the United States.”7

Now that the “why” has been answered, the “what” credential is a bit more challenging. From a sonographer standpoint, achieving a credential in vascular sonography is definitely important and essentially will be required by employers. The RV S or RVT are outstanding and meet the criteria we’ve been discussing, however adding the RPhS after that, in my opinion, would demonstrate a specialized interest in phlebology and should strongly be considered for someone who spends at least 50% of their diagnostic time on venous issues.

From a physician standpoint, the question is: performance or interpretation (or both)? Realizing that a majority of the information does overlap, I would suggest both without hesitation. This, too, appears to have a strengthening link to reimbursement policies and should not be taken lightly. Some Medicare LCD s have implementation dates for minimum requirements of RVT performance of vascular ultrasound. Some of these dates have already passed, which places a physician at risk for recoupment if an audit is performed. There have been an increasing number of Medicare and third-party insurance audits, and one item being reviewed is the minimum competency credentialing for diagnostic studies. A review of the Medicare LCD is probably the best method to understand how this impacts you or your practice. To recap, there are some KEY DATE S:

2014 – Vascular Surgery Board of the American Board of Surgery (VSB-ABS) requirement for the RPVI

2017 – ICAV L to require all technical staff to hold a valid vascular credential by January 1, 2017

It is clear in moving forward that more and more payment policies are going to be linked directly to competence, which is demonstrated through the credentials mentioned above.