Newsletter AMERICAN ASSOCIATION
OF
PHYSICISTS
IN
VOLUM E 23 NO. 2
MEDICINE MARCH / APRIL 1998
AAPM President’s Column Physicists Must Be Involved by Lawrence Rothenberg New York, NY T h e r e ar e ma ny area s of traditional radiology in which m ed ica l p hys ic i sts hav e played an integral role, both in carrying out the clinical p ro c e d u res and in educating the physicians and support personnel involved. These ha ve be en th e tr ad it io nal radiological areas of x-ray imaging which includes computed tomography and mammography, radiation oncology an d b r ach yth e rapy , a nd n uc l ear me d ici ne wit h r ad io nu clid e ima gi ng a n d dosimetry. There are many newer clinical procedures for both imaging and tre a t m e n t which involve either the use of ionizing radiation o r of image evaluation techniques which are being carried out without the significant oversight or involvement of medical physicists. They include magnetic resonance imaging (MRI), u ltraso und imag ing (US), intravascular brachytherapy, di git al card iac “c in e” imaging, and electrophysiology. The physicians involved are cardiologists, neurologists, urologists, and general practitioners, none of whom are ex posed to a rigorous curriculum containing extensive
didactic training in the principles of radiation dosimetry, image evaluation, or radiation protection. We, as medical physicists, must make a greater effort to interact with the se g r oup s an d app ris e them of the great contributions which we can make to the ef f ica cy and sa fety o f their pro c e d u res and to the exp e rt is e of their practitioners. In tradition al ra di ol og y, medi c al phy s ici st s ha ve worked hard to establish a s t rong identity in the field. T h rough AAPM, ACMP, and ACR-CMP, we have cooperated with scientific org a n i z atio ns such as RSNA, SNM , ASTRO and ARRS, with regulatory bodies such as FDA, NRC, CRCPD and state regula to ry age nci es, a nd w i th p rofessional and certifying
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o rganizations such as ACR, A BR, JC AHO , AR R T, and AAMD to guarantee a promine n t p os itio n f or med ic al physics topics and for medical physicists in the graduate education, training, and continuing medical education of radiologists, radiation oncologists, nuclear medicine physicians, radiological technologi sts , ra di at io n thera pist s, and dosimetrists. We have not usually been as successful in establishing our prese nce in th e initial medical sc hool trai ning of
INSIDE TABLE OF CONTENTS President’s Column. . . . . . . p. 1 MRI Scans . . . . . . . . . . . . p. 4 ACR/Reimbursement Codes . p. 6 Executive Director’s Column. p. 9 State Sales Tax. . . . . . . . . p. 10 ABR Computer Exams. . . . p. 11 Annual Meeting Photos . . . P. 12 Announcements . . . . . . . . p. 13
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physicians and in re a c h i n g physicians outside of radiology. Physicians and patients a re often woefully unaware of the relative risks or vario us ty p es of x- ray p ro c ed u r es. I rec en tl y wr ot e a detailed report for, and had a long telephon e discussion wi t h, a p ati ent who h a d u n d e rgon e sev er al r adiographic procedures and was concerned about gonadal and conceptus dose because of a potential pregnancy. When we reviewed the organ doses for the various films taken, I was able to convince her of the very low doses she actually received. As the conversation cont inued, she was quite dismayed to learn that the dose from multiple plain fi l ms of her v ari ou s bo dy parts provided a much lower dose than the abdominal CT exam which had been perf o rm ed o n h e r at ano th er inst i tu ti on . H er pers ona l physician was also ignorant of the relative do se levels involved.
Magnetic Resonance Imaging Many medical physicists are involved in a wide variety of re s e a rch projects involving magnetic resonance imaging and m agne t ic r e s o n a n c e s p e c t roscopy; however, the typical clinical MRI facility h as no me di ca l ph y si ci st involved in routine quality assurance, if indeed such a p ro gr am e xis ts at al l. Typically service personnel p e rf o rm all quality contro l testing. In recognition of this fa ct , t he n e w A C R MR I A c c redit ati on Progr am , a s announced at the 1997 RSNA
session hosted by ACR, does not require an MRI facility to have a QA program supervised by a medical physicist. I t me re ly re q u i r es th a t, if there happens to be a physicist or other “MRI scientist� at the facility, he may supervise the program. (The argument made by those presenting for ACR was that most clinical MRI facilities have no physicist. Of course, a few years ag o a la rge pe rce nt age of clinical mammography facilities had no physicist.) We ha ve o bv i ous ly fa i led to make the case for the significance of our involvement in the routine operation of MRI facilities. This, in spite of the many AAPM documents p roduced for MRI, and the in v olv em ent of nu m ero u s m edi c al p hysi c is ts in p ro duc ing MR I g uidel ines a nd re por ts fro m other organizations.
Cardiology Medical physicists do not have a significant role in cardiology procedures involving ionizing radiation. In most facilities, our limited involvement includes annual calibration of the x-ray equipment in the cardiac cath labs and affiliated electrophysiology xray suites. In general, we do not participate in graduate medical education for cardiologists. In many cases they a re profoundly unaware of, or unconcerned by, the high le vel of radi a tion do se to both patients and personnel a n d of t he v al ue of simple radiation pro t e c t i o n procedures. Cardiologists are now rushing ahead with clinical trials
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of a variety of intravascular br achytherapy pro c e d u re s , sometimes without adequate i nv o lv em ent o f me d ica l physics and radiation safety pe rs on nel. Th e Nuc le ar Regu lat ory Com mi ss io n i s currently considering requirements for personnel involved in such pro c e d u res. Since these procedures will involve high doses and dose rates of gamma or beta radiation, it is essential that medical physicists be involved in impleme nt atio n of thes e pro c edures and also in the training of all participating physicians in the principles of radiation and protection.
Ultrasound Imaging Although the AAPM has a very active group of physicists involved in ultrasound, most clinical ultrasound facilit ies h av e no o ve rsi ght or input from medical physicists. A r e ce n t f ea tur e s to ry by D ia ne S aw ye r of A BC Television exposed the wide va ria tion in th e qu ali ty o f ultrasound imaging performed not only by internal medicine physicians, but by radiologists and other imaging specialists. Medical physicists have failed t o es tab li sh the ms elve s as important players in the ultrasound QA process. I must reluctantly admit that much of the reason for the weakness of ultrasound (and MRI) Q A p r og ra ms is a la ck of invo lvemen t by re g u l a t o r y agencies in the certification and inspection of the faciliti es, because the imaging process does not involve the u se of i oni z in g ra di ati on . The initial ACR ultraso und accreditation program did not
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have a significant technical quality contr ol component involving medical physicists. The urologists, general practit ione rs , a n d ot her s who employ ultrasound, often for financial gain rather than clinical information, have essentially no training beyond a few ho urs a t train in g pro grams conducted over a single weekend.
What Should We Do? 1. Pa rt i ci pa t e i n t he activities of organizations of c a rdiologists, urologists, surgeons, electro p h y s i o l o g i s t s , and of lo cal medical soc ieties. Submit papers for presentation at the annual meetings. Make contact with the leaders to request appointm en t to k e y co m mit t e es . Highlight the expertise and experience which medic al physicists can bring to such organizations. 2. D ev el op i n-s e rv ic e programs for physicians, techno lo gis ts , and nu rses in the hospital departments bey o nd r ad io lo g y w hi ch em plo y radi a tio n or
imaging devices. 3. If you are employed at a university, contact the medical school dean and attempt to include a few lectures on physical aspects of imaging, radiation oncology, radionuclides, and radiation pro t e ction in the standard curriculu m. Make the same p itch to the directors of residency p rograms in non-radiological a reas which rely heavily on i ma gi ng and ra di at i on t reatment. It is not easy to modify such programs, but s ev er al i ndi v idua l s h a ve a l ready done so at selected institutions. 4. E ducat e f edera l an d state legislators and regulators about the importance of medical physicist involvement in p ro c e d u r es i nvo lv in g n ew radiological techniques as well as in imaging areas involving non-ionizing radiation. Stress the need for physicist supervision of quality assurance programs and participation in the t rain in g of ph ysi ci ans a nd s upport p ersonnel. At the 1998 Annual Meeting of the Congress of Radiation Control
P rogram Directors (CRCPD), t he AA PM is pr es e nt in g a sp ec ial sy mpo si um a bo ut image quality and risks over the entire spectrum of imaging techniques The recent intense involvement of medical physicists in th e est abl is hm ent of h igh qual ity , saf e ima gi ng p rogr am s in mamm o gr aph y t h rou g h t he A CR Mammography Accre d i t a t i o n P r o gra m a nd t he f ed e ra l M am mog rap hy Q ua lit y S t a n d a rds Act should serve as our guideline. Medical physicists worked closely with ACR Committees and staff , and with FDA and state regula tor y a gen c ies , t o ins u re strong physicist credentialing, meaningful re q u i rements for continuing education, and rele va nt ph y si cal t est s w ith appropriate phantoms for the quality assurance and certification programs. In addition, AAPM, ACMP, and ACR provided many opportunities for medical physicists to obtain C at eg ory I ma mm ogr ap hy CME credits at annual meetings and regional seminars. â–
DON’T FORGET You can send revisions for your Directory Address, as we ll as your address(es) for M ailings, Billings, and Correspondence, at any time through the AAPM Web Page:
http://www.aapm.org NOTE: These are not automatic changes to your file. Your submission will enter a queue and will be processed as quickly as possible.
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MARCH / APRIL 1998
Who is Safe to Scan with MRI? by Allen Elster, MD Winston-Salem, NC Every year, several MRI scans a re improperly cancelled because of lack of knowledge concerning safety and screening of implanted devices. Although there is an appreciable published literature on the subject and I lecture on this subject every year, considerable misunderstanding remains. I have therefore constructed this memo to serve as a quick review and guide in deciding which patients can (or cannot) be safely scanned. As a general principle, there are only a few absolute contraindications to MRI, and it is t h e re f o re much easier to remember the exceptions.
1. To be explicit, please note that it is generally safe to scan anyone with the following devices: • Internal orthopedic hardware ( s c rews, plates, rods, nails, wires, artificial joints). • Surgical clips, staples, wires, mesh, sutures (time of surgery doesn’t matter). • Diaphragms, IUDs, tubal ligation clips. • Penile prostheses. • Intravascular stents, coils, and IVC filters (if implanted longer than 6 weeks). • Stapedectomy pro s t h e s i s , tympanostomy tubes. • Lens implants, scleral bands. • Neurosurgical shunts, mesh, and clips (not on aneurysms). • Synchromed infusion pumps. • Metal cardiac valves.
2. As a general rule, patients with the following items should not be scanned: • Implanted electronic devices (pacemakers, internal defibrillators, cochlear implants, nerve or bone stimulators). • Cerebral aneurysm clips (but see item 3 below) . • Ferromagnetic foreign bodies in critical locations (but see item 4 below). • Certain rare devices: eyelid springs, magnetically activated tissue expanders. • Various ICU related appliances (See TABLE 1).
we require that the radiologist see a written confirmation of the exact type of clip-generally by obtaining the operative note, or obtaining the same in writing from the neurosurgeon.) A verbal recollection is not acceptable. Please note also that this precaution applies to cerebral aneurysm clips only; clips on abdominal aortic aneurysms may always be scanned.
4. Most metallic foreign bodies (bullets, shrapnel) can be safely scanned, unless they are ferromagnetic and TABLE 1: Supplemental Screening Check List for Inpatients embedded in Implant or Device Recommended Action a critical locaExternal infusion pump for IV medications All IV catheters should be converted to tion (e.g., eye, (e.g., IVAC, IMED) free flowing or Hep-Locked Arterial catheter Remove associated monitoring/recording brain, lung). Intracranial pressure monitor (bolt) Skin staples Orthopedic appliances (including Halo, tongs, skeletal fixation) Ventricular and surgical drains Thoracostomy tubes
Metal tracheostomy tube Indwelling catheters, especially Swan-Ganz type with thermal dilution tip ECG or electroencephalographic electrodes, pads, or leads Holter/telemetry monitor Pulse oximeter Temporary pacer wires Transcutaneous eletrical stimulator unit/patches
equipment Remove associated monitoring/recording equipment Remove if possible; otherwise cover with bandage MR may contraindicated: direct consultation with radiologist Remove all metal clamps and containers from circuit Many reservoir devices (e.g., Pleur-evacs) are not MR compatible; tube must generally be clamped with nonferromagnetic instrument Exchange for plastic model MR may be contraindicated; direct consultation with radiologist Remove Remove Remove Remove Remove
3. Certain cerebral aneurysm clips may be safely scanned. A large number of cere b r a l aneurysm clips have been tested and found to be MR compatible. Lists of these “safe clips” are available in the MRI center. However, as a policy
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First you should note that a potential danger only exists for objects which are ferromagnetic (i.e., able to be picked up by a magnet). F o reign bodies made of copper, aluminum, or lead are safe to scan no matter w h e re they are located. Because virtually all community a c q u i red bullets are made of lead, they are generally safe to scan regardless of location. Many shotgun pellets, as well as bullets and shrapnel acquired from military service, are ferromagnetic, however, and
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further consideration is in order. If they are embedded in a critical location (such as the brain, lung, spine or eye), I generally do not scan the patient. If they a re embedded in muscle or subcutaneous tissue, they are likely to be encased by scar and will not move; I would therefore generally allow these patients to be scanned.
5. Protocol for foreign bodies in and around the eye. Many patients report a history of having been struck in the eye by flying metal, perh a p s related to industrial employment. After questioning the patient about this matter further, the radiologist or technologist should first decide if there is a reasonable chance that a metal fragment still remains in the eye. If so, the patient should be re f e r red for plain films of the orbit before scanning. By “reasonable chance”, I mean situations like the following: (1) that the patient specifically remembers being struck by flying metal, and thinks that there is a fair probability that it still remains in the eye; (2) that a foreign body was previously removed from the eye by a doctor or nurse (carrying the risk that additional smaller fragements were not removed); or (3) someone has told the patient they have seen metal in his eye on previous x-ray. As a rule, it is still OK to scan a patient even if the xray reveals small metal shavings, provided these shavings are not within or behind the g l o b e . This is a distinctly uncommon occurrence, because the sclera and orbital fascia is usually quite tough and resists
the entry of small fragments. Thus nearly all patients with suspected orbital foreign bodies will prove safe to scan.
6. Scanning pregnant patients is OK, but talk to them first. At present there is no consistent or convincing body of scientific evidence that MR scanning endangers the developing fetus. Because of unknown potential effects, however, we do not cavalierly recommend MR imaging in pre g n a n t patients, particularly if there is no strong clinical indication for the scan. Reasonable indications during pregnancy include h e rniated disk, pituitary dysfunction, or suspected brain tumor. Before scanning a pregnant patient we have the requesting physician sign a form (available from the MRI front desk) that he deems the exam medically necessary. Next, I insist that the resident or fellow talk to the patient and explain the risks/benefits. My personal spiel is something like the following:; “Hello, Ms. X. Your doctor has sent you today for an MRI scan. We know that you are pregnant and I want to tell you a little about the scan and to get your permission to proceed. To the best of our medical knowledge, there is no proven harmful effects of MR imaging to babies in the womb. If my wife were pregnant, I would have no reservations about sending her for a scan. Also, most other tests to diagnose your problem (like CT or myelography) would expose your baby to x-rays,
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which would likely pose the same (or even greater) risk. We think that the potential benefit of your having this MRI scan significantly exceeds any risks it may pose to you or your baby, and therefore ask you to sign this consent form. Do you have any questions?” As a rule, I do not give gadolinium to pregnant patients unless a tumor is seen on the precontrast study or there is a question of infection. If gadolinium is given to a lactating mother, I r ecommend stopping breast feeding for 1 1/2-2 days.
7. What about devices not on the list? As in all branches of medicine, it is difficult to protocol every possible situation. If you have any doubt about the suitability of scanning a patient, call me. Often, the answer will be, “I don’t really know if there is a risk because there is no published data on the subject.” What you decide to do will there f o re depend on weighing risks and benefits of the procedure. Good luck! ■ Dr. Elster is a Professor and Director of MR Imaging at Wake Forest University School of Medicine, Editor in Chief of the Journal of Computer Assisted T o m o g r a p h y, and tea ches an advanced course in MR physics. We realize that controversies exist concerning the safety of scanning patients with certain implants and medical devices. Nevertheless, this protocol has served us well, allowing us to safely scan over 80,000 patients during the last decade. As with any medical procedure, clinical judgement involving potential benefits versus risks should be excercised for each patient.
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ACR Commission on Medical Physics Medical Physics Reimbursement Codes by James Hevezi San Antonio, TX T he C omm it t ee on Ec on omic s und er th e C omm is si on on Me d ic a l P hys ic s o f t h e Am eri c an C ol le ge o f Ra di ol ogy w as i ns tit ut ed i n 19 85. I t w as f o rmed to address the econo m ic c onc er n s of t he Medical Physics community as they relate to health care delivery activities of Medical Physicists. Although these activities run the gamut of Medical Physi cs su b-fields (D ia gn ost ic, Th er apeu ti c , N uc lea r R adi ol ogi cal and Healt h P hys ic s) , the chi ef a rea of eco no mic concern has historically been in the Therapeutic Medical Physics realm. This is so, re c e n t l y , becaus e th ere are explici t reimbursement codes that the American Medical Association has recognized belong to the delivery of Medical Physics services under the Curre n t P roc ed u ral Te rm i n o l o g y (CPT) codes in the field of Radiation Oncology. These a pp e ar in t he CP T 7 73X X series of the AMA CPT publication and have been relegated to the technical component of reimbursement. To reorient the reader, CPT c o des a re s pl it i nto P rofessional and Te c h n i c a l reimbursement components. Patient care activities are categorized as belonging to one or another of these, or some fraction of both. As Medical
Physicists working in the field of Radiation Oncology, we have become looked upon as integral members of the cancer care team and our visibility with re g a r d t o exp li cit p ati ent c ar e ac tivit y re i mbursement is reflected in this service delivery. The CPT 773XX series of Medical Physics re i m b u r s ement code examples include technical reimbursement for such activities as monitor unit and point dose calculations (77300), computer calculated isodose distributions (77305315), brachytherapy computer calculated isodose distributions (7732x-328), and several others (14 total). Several of thes e codes carry multiple CPT designations to re f l e c t the work done in support of the patient treatment course as being Simple, Intermediate, o r Co mpl ex w ork . Th ese ex am p le s in cl ud e both a P rofessional re i m b u r s e m e n t component that reflects the w ork p e rf o r me d by t he Radiation Oncologist, and a Technical component reflecting the Medical Physicist’s e ffort (or Dosimetrist under the direction of the Medical Ph ysi ci st). Th ere are two codes which are relegated to Technical only in this series: C PT 7 7 33 6 C o ntin ui ng Medi cal R adiat ion P hys ics Consultation… and CPT 77 37 0 Spe ci a l Me dic a l R ad ia t ion P hys ics Consultation. The work perf o r med by the Me dic a l Physicist reimbursed by these c o des i s v ie we d as n ot
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requiring physician input, sa ve for t he r eq ue s t an d d i r ecti on o f t h e R adi ati on Onc ologi st. Ot her c od es, such as the series CPT 772613, T herap eutic Radio lo gy Tr eat men t Ma nag eme n t, include only a Pro f e s s i o n a l component and are viewed as no t re qui rin g t ech ni cal input. In addition, the overall CPT series 77XXX includes treatment delivery, treatment simulations, and others, with P rofessional, Technical, or b oth componen ts of re i mbursement specifically contained within each procedural en t it y. Yo u ma y re fe r to G e o ff Ibbott’s articles published in earlier editions of the newsletter describing the Abt survey and work eff o r t f or M edi cal Ph ysi cs CPT codes. The scene b ecomes a bit m o re c o mp l ic at ed w hen H os pi ta l bas e d Rad ia t io n O ncol og y prog ram s and Sta nd A lo ne Rad ia t io n Oncology programs that bill “globally” are considere d . If, in the hospital based program, the Radiation Oncology department forms one of the several departments in the hospital, the hospital receives the Technical component of billing (usually referred to as “Part A” of Medicare re i mbu rse me nt) , w hi le t he Radiation Oncologist is reimbu rse d th roug h t he P rof es si ona l c ompo nn e nt “Part B” of Medicare re i mbursement). Hospital based p rograms such as these generall y employ the Med ica l
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Physicist or have the Medical Physics work done under a contractural arrangement with a private practice Medical Physics group. For the case of the Stand Alone Radiation Oncology programs that are owned by physician gro u p s , th e pr evi ou sl y sep ar at ed P rofessional and Te c h n i c a l c omp one n ts of pa ti e nt charges are “lumped” togethe r in to a si ng le glo ba l charge, roughly amounting to the sum of the Pro f e s s i o n a l and Technical components. Again, the physician gro u p s w i ll em pl oy the Me dic a l Physicist or contract out the work to a private practice Medical Physics group. As mentioned earlier, the AMA annually publishes the CP T l is ti ng co v erin g a ll health care delivery specialties and their unique re i mbursement codes, summary d e scr ip t ors d e fin in g each code, and changes to these c odes th at ma y h ave o c c u r red since the last CPT p ubl i cat i on. Th e lat ter include new codes approved since the last CPT listing was p ublished, and cover new p ro c e d u re s th e app r o v a l p rocess has deemed necess a ry for goo d h ealt h c ar e de liv ery . I n R adi ati on Oncology, the last set of new C PT code s a pp rov ed an d published occurred in 1994 and covered the pro c e d u re s involved in plan ni ng and management of stere o t a c t i c radiosurgery (CPT 77432) and conformal treatment management (CPT 77419). These tw o co de s w er e a lloc at ed p rofessional only status; but it was quickly observed that considerable levels of new
technical input were required to perform these new procedures. Therefore, CPT 77295 was adopted in addition to these two codes to cover the technical reimbursement for the additional work required t ec hni ca ll y to pr o duce a stereotactic radiosurgical plan or 3D conformal plan. For several reasons at the time of adoption, this code (77295) appeared under the group of codes in the Simulation series (77280-290) and, as of the A MA C P T 96 pu bl ica t io n, re q u i red radiation tre a t m e n t t o be de li vered w ith non coplanar beams. The definit io n in CP T 96 w as: CPT 77295, Therapeutic radiology simulation-aided field setting by three-dimensional re c o nstruction of tumor volume in p r ep ar ati on fo r tre a t m e n t with non-coplanar therapy b e am s . T hi s c od e has a high relative value assigned t o i t co m par ed to oth er Radiation Oncology codes, and although it has both a p rofession al and technical component assigned to it, the bulk of the re i m b u r s e m e n t falls in the technical realm. The global value is correspondingly high reflecting the l a rg e am o un t o f ef f ort i n p lann in g su ch co m pl ex patient radiation procedures. In the past two years, the a ct ivi ti es o f th e CMP Economics committee have revol ved ab out re d e f i n i n g CPT 77295 and addre s s i n g the “bundling” of CPT 77336 a n d C PT 77 37 0 p er t he C o r r ec t Co di ng Ini t ia t iv e (CCI) implemented by th e Hea l th Ca re Fi nan c ing Ad min is tr at i on ( HCFA ) . Th ose A AP M me mb e rs of
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ACR may refer to several articles publis hed in the ACR Bulletin regarding these activities. Briefly, CPT 77295 was originally intended to re i mburse the work re q u i red to develop a 3-D treatment plan that was to be treated using non-coplanar beams, chiefly t reating stereotactic targ e t s . In the interim, 3-D simulation and planning systems became available for conformal radiotherapy, and although the amount of work to pro d u c e a 3-D plan increased fro m that reimbursable thro u g h C PT 77 315 , if the pat i ent happened to be treated with a cop lan ar b eam ar ran ge me nt , th e re i m b u r s e m e n t remained at CPT 77315 level s. Wi th CP T 19 98, t he descriptor for CPT 77295 will a llow re im bur se me nt f or coplanar beam arrangements for 3-D planning and tre a tment. Very specific pro c ed u res must be adhered to, h o w e v e r, in order to charg e this code for patient tre a tme nt . Thes e ar e als o described in several articles t hat a re o bta in abl e fr o m ACR’s Office of Economics. CCI’s “bundling” of codes addresses those activities that, if o ne pro c e d u r e i s p er formed and charged, another code covering similar activities should not appear on the pat i ent ’s b ill o n the s am e date of service. The codes originally approved for reimburs ement are cont inual ly reviewed for charge frequency and appropriateness by the CCI under contract with H C FA, and appear as “edits” t o t he C PT (A M A) li st i ng p ubl i shed fo r the yea r. Thes e a nnu al “ edi ts ” ar e
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p ub li she d by CC I an d are a vail a ble t h ro u g h l o c a l / re gi on al c a rrie rs or t h rough NTIS Subscription D epa rt me nt re ach ab le a t (703) 487-4630. CPT 77336 a nd CPT 7 737 0, al t hou gh describing different activities that Medical Physicists perf o rm i n su pport of patient t re at me nt co urs e s, we re vi e we d by C CI a s bei ng mutually exclusive; that is, if a Continuing Physics Consult c h a rge is per f o r m ed for a patient treatment course, then a Special Physics Consult was viewed as being incorporated by the original charge, if performed additionally. And the reverse was viewed as mutually exclusive as well. Part of the problem was a misunderstanding on the part of C CI as to w hat Me d ic a l Physics work is involved in each pro c e d u re. The ACR responded to the CCI “edit” ex p la i ni ng in d e ta i l t he M ed ica l P hy s ics ac tiv it ies involved in both pro c e d u re s , but at this juncture, CCI has retained the edit. Hence, if these charges are billed on the same date, likely one will be disallowed by the carrier. ACR continues to object to the edit and the hope is that we will prevail in convincing CCI to remove this edit. B esi des t he i nf o r m a t i o n contained in the annual publication of AMA’s annual CPT listing, each specialty has the oppo rtunit y to in st ruc t its members in the appro p r i a t e use of the r e i m b u r s e m e n t c ode s in mor e de ta il t han that contained in the publication. Because the original sp ec ial ty re i m b u r s e m e n t codes originated through spe-
cialty committee re c o m m e nd a ti on s t o the A M A a nd, eventually, HCFA incorporation to the annual CPT publicat i on, me di cal nec es si ty rationale and other detailed aspects in the production of each reimbursement code are available through the specialty societies. Questions concerning aspects of Medical Physics code reimbursement may be referred to the ACR O f fice of Econo mics fo r i n t e r p re t a t i o n . If the ACR s t a ff is unable to resolve a particular question, the staff will refer the question to the a p p ro pri at e co m mit t ee to resolve. A detailed ACR guide to CPT coding for Radiation Oncology procedures is currently in production and should appear in 1998. Input from the Medical Physics community as well as other professional societies involved for each code was obtained. Impetus for the ACR’s guide production came from one of Medicare’s Carrier Medical Director’s of f i c e requesting input from ACR to p roduce what is termed by HCFA, “Local Medical Review Policy” covering these procedures. Although not a national policy for Radiation Oncology procedures, local carriers are encouraged to adopt these policies with as little change as possible to motivate continuity of policy between carriers. In a future article, I will describe how a new CPT code m ov es thr oug h the “system” for r e i m b u r s em e nt a pp r o v a l , an d the position of Medicare’s Carrier Medical Directors in determining r eimbu rsemen t pol icy. ACR’s inter fac e to th ese
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D i r ect or s ar e t he C arri er Advisory Committees and provide insight into these mechanisms for reimbursement policy modification. There are many new approaches being investigated (Managed Care , Ambulatory Patient Gro u p s , Compliance Reviews, etc.) for health car e r e i m b u r s e m e n t and I hope to describe these to you as well. ■
AAPM NEWSLETTER
MARCH / APRIL 1998
Executive Director’s Column By Sal Trofi College Park, MD 1998 AAPM Summer School The 1998 AAPM Summer School will be held June 21-25, at the University of Wisconsin - Madison. Bruce Thomadsen heads up the Local Arrangements Committee. There will be two separate educational programs that will run simultaneously. Imaging in Radiotherapy is the topic of the larger school. The Program Directors for the larger Summer School are Art Boyer and John Hazle. Advances in Nuclear Medicine: The Medical Physicist’s P e r s p e c t i v eis the topic of the Mini-Summer School, which will be held June 21-23. The Program Directors for the mini school program are Michael Yester and Stephen Graham. Registration material for both schools was in your monthly mailing packet last month. The same information can be found on the AAPM web site (http:\\www.aapm.org). Please contact headquarters if you need assistance with registering for either school.
Membership Directory Your copy of the 1998 AAPM Membership Directory should have reached you by now. The directory was mailed during the last week of February. We experienced some difficulties in getting the directory published by our target date of January 1. The staff has a plan
to improve the pro d u c t i o n process for next year and you can help if you have access to the Internet. Among the various steps in the process is the matter of changes to demographic information. In the past, each member received a questionnaire annually which lists current information in our database with space provided to write in changes or additions. This manual process is very time consuming and prone to error in interpreting handwriting. We will remind you by e-mail throughout the year that you can send revisions for your Directory Address, as well as your addresses for mailings, billings, and correspondence, at any time through the AAPM Web Page. For control purposes, e-mail changes are not automatic changes to your file. Your submission will enter a queue and will be processed as quickly as possible by a staff member. About 70% of AAPM members have e-mail access. If a good portion of those send in changes over the course of the year, it would greatly help us s p read the workload and deliver the directory on time.
Financial News The news is good! For the forth-consecutive year, the AAPM finances are in a positive position. The main reasons for the 1997 year success are 1) better investment p e rf o rmance, more re v e n u e from Medical Physics Journ a l non-memb er subscriptions and advertising revenue, and 2) more exhibit space sold at
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the AAPM Annual Meeting. On the expense side, I am glad to say, we were substantially under the budget allowance. The Tre a s u rer will report in greater detail in a subsequent issue of this newsletter.
Staff News Penny Atkins, AAPM’s Manuscripts Editor, will be married on May 9, 1998. Her husband to be is Mike Slattery. This is a great story. Mike and Penny went to grade school together and lost contact with each other for many years. A few months ago Penny’s mother met Mike’s parents at a doctor’s office, they discovered during their conversation that both their children were not yet married. Mike called Penny a few days later to arrange a date to talk over old times. The first date led to another and that led to a proposal of marriage. Mike Wo o d w a rd, AAPM’s Internet Services Manager, and his wife Anne have bought a new townhouse. They were renters before and now they a re homeowners. Mike and Anne recently moved into their new townhouse in the midst of a Nor’ Easter. ■
AAPM NEWSLETTER
MARCH / APRIL 1998
New York State Sales Tax on Physics Services ACR to the Rescue by Bob Pizzutiello Bronx, NY I wanted to have my letter to Steve Amis published so that all medical physicists could be made aware of the potential p roblems with State Sales Ta x , although the rules are diff e re nt w i th ea ch st a te . I a l s o wanted to point to this case as an answe r to th e oft pos ed question “Why should I as a Medical Physicist be a member (pay more dues) to a professional organization such as the ACR, since I am already a member of the AAPM.” This was c le ar l y a mat te r fo r a p rofessional org a n i z a t i o n , and in my opinion, only the ACR had the re s o u rces and clout to bring this to a succesful conclusion. Dear Dr. Amis: Since October, 1995, I have had a number of discussions with th e AC R Gov er n m e n t Re l at io ns Of f ice a nd th e NYSRS re g a rd in g ou r New York State Sales Tax Audit. I am wri t in g t oday to t ell you of ou r succ ess a nd t o th an k t he S oci ety f o r it s invaluable support. In October 1995, my medical physics prac tice was audited for New York State Sales Tax compliance. The auditor maintained that our services include “diagnostic testing of taxable equipment. which is taxable.” We maintained that our services are professional in nature and not fundamentally diagnostic
testing. I sought the support of the NYSRS in our battle. The Society was extre m e l y supportive, offering the assistan ce o f Mr. Ph il Pins k y in th e pre pa ra tion of our defense. Phil Pinsky took the lead in preparing the case, which eventually was reviewed at a Tax Conciliation Conference. After our initial meeting, Phil Pin sky an d his coll eag ue, Bob Kent, researched the tax law, State and Federal re g ulations. They worked closely with Joe Grymin, my accountant, and me to create a veritable mound of documentation supporting our case, O n O c tobe r 14 1 199 7, Me ss rs. Pi nsk y, Kc nt a nd Grymin re p resented Upstate Medical Physics at the Ta x Conciliation Conference in Alban. Within a few weeks, we received a notice that all claims for New York State Sales Tax had been dropped, copy enclosed. This important ruling sets a p recedent and will pro t e c t Radiologists from the added b u rden of unfair taxation. Indeed it may be prudent to bri ng t hi s to t he N YSR S members’ attention in th e event that some may have a l ready been charged sales tax for medical physics services. I have already authorized Phil Pinsky to publicize this result in any way that ben e fi t s me mbe rs of ou r society. Although it cost my g roup a significant amount of time and money to fight the sales tax audit, the result
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was well worth the cost and a clear benefit to the members of the Society. In re t rospect, it is abundantly clear to me that my r e s o u rc es a l on e wer e too li m it ed to suc ce ed i n t his ca se. Th e re s o u rc es and backing of the NYSRS was not only key to the successful preparation of the case, but also sent an important me s sage o f u ni ty t o t he Department of Taxation . I a m o f t e n as ke d by m y medical physics colleagues “why should I be a member of the ACR or a State Chapter?” This is an excellent example of what the society can do for its memb e r s and I intend to spre a d th e w ord t o Brad Sh ort a t ACR, Do n Tol bert and t he greater medical physics community. Once again, many thanks for your su pport. You can con ti nu e to co un t o n my active support of the NYSRS and the ACR. ■
AAPM NEWSLETTER
MARCH / APRIL 1998
ABR Moves Toward Computer-Based Examinations by William Hendee Milwaukee, WI Over the 1997 Labor Day weekend, the American Board of Radiology held a retreat in Vail to discuss certification examinations of the future for radiologists, radiation oncologists and medical physicists. One outcome of the re t re a t was appointment of an ABR Computer-Based Examination Committee (CBEC) consisting of the following individuals: Helen Redman MD, radiologist; Steven Leibel MD, radiati on on co lo gis t; R ichard Rovinelli PhD, consultant; David Becker, ABR informatics specialist; Anthony Gerdeman MS, biometrician; and Paul Cap p MD, ABR Executive D i re c t o r. The committee is c h a i red by William Hendee PhD, medical physicist. The CBEC held its first meeting in Dallas on January 8-9, and p re p a red the report summarized below. T his re p o r t , including all re c o m m e n d ations, was approved by the ABR Board of Directors at its annual meeting on February 1-6, 1998. C o m p u t e r-based examinations have many advantages over w ritt en cert ificatio n examinations, including: ■ E nhanc ed f lexibil ity; ex panded test ing at th e pass/fail margin ■ Pass/fail decisions separated into categori es; amenable to adaptive testing ■ G reater scoring ea se/ accuracy; enhanced statistical evaluation
■ G reater range of question format s; p resentation of i m a ge s, c olo r, m o ti on , sound ■ Software upgrades easily added ■ G reater org a n i z a t i o n a l control ■ M u lt i p l e e x am s c an be offered ■ Flexible presentation of test items ■ Legal accountability ■ Selection of items fro m test-item database ■ Monitor candidate performance during exam ■ C a n d i d a t e c a n t r a ck progress during exam ■ H e lp s m e e t A D A requirements ■ C o s t - e ffective over the long term They also have some disadvantages, such as: ■ Front-loaded cost ■ Candidate unfamiliarity with computers ■ More exams and test items needed ■ Establishment of equivalency among exams Perhaps the greatest disadvantage of computer- b a s e d examinations is their demand for change by both examiner s and ex am i nees. A cco mm od at i on t o th is change is one of the ongoing challenges to be managed by the CBEC. The CBEC, and the ABR by en dors eme nt of the CB EC report, believe that societal and professional demands for accountability will re q u i re computer-based examinations for t he enti re certificat ion p ro ces s i n th e f utu r e .
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H o w e v e r, the groups re c o gnize that there is at pre s e n t no ac c ept abl e c ompu ter b ased replacement for the oral examination. They also a ck no wl e dg e t h e nee d to e s ta b li sh a te s ting an d research center for computerbased examinations to permit the ABR to implement comp u t e r-based testing in a systematic manner without being rushed. The Board intends to focus its computer- b a s e d efforts initially on recertificati on , beg in ni ng w ith R a di ati on On c olo gy and CA Qs in D ia gn ost i c Radiology. The first written certification examination to be a dm inist ere d with c omp ut er te c hnol ogy i s l i kel y t o be f o r med i ca l p h y s i c i s t s , a lt ho ugh th e written certification examination in physics and radiation b io log y fo r radiologists is also highly amenable to computerization. Upon the re c o m m e n d a t i o n o f the CB EC , th e ABR has approved the installation of a c o m p u t e r-based testing and re s e a rch center at its headquarters facility in Tu c s o n .
AAPM NEWSLETTER
MARCH / APRIL 1998
T he ce nt er wil l p r o v i d e a p p roximately 30 test workstations separated by movable partitions, with each workstat io n c on si stin g of a hig hcapacity PC with state-of-theart graphics and a 19-21 inch monitor with 1600x1280 resolution. The PCs will be connec t ed to a 1 00 M bit/ se c client -ser ver network with high redundancy, security and reliability. Also available will be a reception area for candi-
dat es an d an i nst ructi onal a r ea f o r fami li ari zat ion o f examinees with the computerbased examination process. O ne po ss ib il ity i s t he s h a red use of testing centers among various pro f e s s i o n a l o rganizations so that costs can be reduced and test centers can be distributed geographically. To explore this p os si bi li ty , t he A BR h as opened discussions with the American Board of Obstetrics-
AAPM/Siemens Cocktail Party Annual Meeting Milwaukee, WI
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Gynecology, American Board of Fam il y Pra ct ic e, and American Board of Pathology. In any event, the ABR plans t o ha ve i t s t est in g and research center functioning by t he f ir st of ne xt yea r, an d hopefu ll y by No vember in time for the first voluntary certification examination for radiation oncologists. â–
AAPM NEWSLETTER
ABR to Increase Emphasis on Magnetic Resonance by William Hendee Milwaukee, WI Magnetic resonance continues to grow in importance in di ag nos tic m edi c in e . A s a reflection of this importance, the phys ics trust ees of the American Board of Radiology a re interested in incre a s i n g t he em ph a sis on mag ne tic resonance in the written and oral examinations for diagn os it c m edi cal ph y si ci st s . They are soliciting input from the medical physics community about the desirability of this increased emphasis for the certification process. Comments are encouraged and should be directed to: Bill Hendee (whendee@mcw.edu) â–
MARCH / APRIL 1998
Announcements Nominations for ICRU Gray Medal Invited The International C o mm is si o n on R ad i a ti on Uni ts a nd M easurements (ICRU) is seeking nomination s for the eighth award o f t h e I CR U G r a y M e d a l . The Gray Medal was establish ed b y t he ICR U a nd is awar ded fo r outs tand ing c o n tr i b u ti o n s t o b a s i c o r medical radiation science of i n t e rest to the ICRU. It hono r s t h e l a t e L o u i s H a ro l d Gr ay, former m embe r and Vice-Chair man of the Commission. The eighth award will be made at the 1 1th I n t e r na t i o na l C ong r e ss o f Radi ation Research in Dublin, Ireland 1999, Nomi nat ions for the medal may be made by any pers on or organization. They must include a comp l ete b i o g ra ph ic a l s k et ch (curriculum vitae) of the nominee, selected re p r i n t s or re c o rds which show the signi fcan t contributio ns made by the nominee, and letters of support evaluating the importance of the contributio ns. No min ations sh o u ld b e di r ec ted to th e Chairman of the I n t e r na ti o na l Co mm is si on on Radiat ion Units and M e a s u r e m en t s, S ui te 8 0 0 , 7 9 1 0 Wo o d m o n t Av e n u e , Bethesda, Maryland 20814, U.S. A., and must be received by the ICRU no later than 15 July 1998. F or additio nal in fo rm a t i o n
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contact: Roger Ney Chief Operating Off i c e r I n t e rnational Commission on RadiationUnits and M e a s u re m e n t s 7910 Woodmont Ave., Suite 800 Bethesda, MD 20852 Phone: (301) 657-2652 Fax (301) 907-8768 E-Mail: icru@icru.org
1999-2000 Fulbright Awards for U.S. Faculty and Professionals Opportunities for lecturing or advanced research in over 125 countries are available to college and university faculty and pro fes si on als o ut side academe. U.S. citizenship and the Ph.D. or comparable profe ss io nal q ual ifi c ati on s re q u i r ed . F or l ec tu r in g a w a rd s, uni ve rs it y or college teaching experience is expected. Foreign language sk il ls ar e ne ede d f or so me co un tr ie s, bu t mo st lec tur i ng a s sig nme nts are in English.
Deadlines: August 1, 1998, for lecturing and re s e a rch grants in academic year 1999-2000. May 1 , 19 98, for d istinguished Fulbright chairs i n We s t e r n E u r o p e a n d Canada. N ov e mb e r 1 , 1 99 8 , f o r i n t e rnational education and acad emic administrator seminars. Contac t the USIA
AAPM NEWSLETTER
MARCH / APRIL 1998
Announcements Fulbrig ht Senio r Scholar Program, Cou nc il f or I n t e r n ational Exch ange of Sc ho lars , 3007 Tilden S t r ee t, NW, Su it e 5L , Box G N E WS , Wa s h in g t o n , D C 20008-3009. Telephone: 202-686-7877. Web page (on-line materials): http:www.cies.org . E-mail: apprequest@cies.iie.org ( r e q u e s t s f or a p pl ic a t i o n materials only).
Maze Measure m e n t s Volunteers are needed to c ollect dat a fo r NCRP Co mmittee SC46-13/AAP M T G-57 (rewrite of therapy shielding portion of NCRP Rep ort #49) . This pro j e c t r e q u i r e s m e a su r e m e n t o f the photon dose at a number of p oi nt s i n the maze of your high energy accele rator(l2 MV and gre a t e r ) . A tota l tim e of about 4 hours w ill be needed to carry out the prescribed pr ot ocol. Anonymous r esu lts o f t he p roj ect w il l be shared by all participants. Please contact Patton McGinley at the address s hown belo w if you can d onate your time to this important undertaking.
April 2-3, 1998
Sunday, August 9, 1998
1998 SEAAPM Symposium “Quality Control in Digital Imaging and Mammography” Holiday Inn East Memphis, Tennessee
Dinner Invitation in Commemoration of: Madam Marie Slodowska Curie for her discovery of Radium and Polonium and for her pioneer work in Radioactivity.
The symposium covers topics in diagno stic radiolo gy including mammography as w el l as rad ia tio n t he rap y . In cl ud ed i s a ste re o t a x i c b reast biopsy workshop that will fulfill ACR qualifications. Attendees may earn 5.5 hours of m am mog r ap hy M Q SA CEU’s. For further inform at io n see t he S E AA P M w e b page: http://radweb.mcg.edu/webd i rectory/seaapm/ or contact course coordinators: Ray Tanner Univ. of Tennessee 800 Madison Ave. Memphis, TN 38163 901/448-6110 rltanner@utmem1.utmem.edu Bob Wilson Univ. of Tennessee 800 Madison Ave. Memphis, TN 38163 901/448-4274 rwilson@utmem1.utmem.edu
Patton H. McGinley phone (404)778-3535 e-mail: pattonradonc.emory.org Emery Clinic Dept. of Radiation Oncology 1365 Clifton Road Atlanta, GA 30322
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P re - r egi str ation must be d on e by Jul y 1, 1 998. S ee AAPM registration package for time, location and cost. This is sponsored by the Task G r oup on Wo men i n the AAPM.
AAPM NEWSLETTER
MARCH / APRIL 1998
How Do the New Final Mammography Rules Compare with the Interim? Corrections The tables presented on pages 10 through 17 of the January/February 1998 AAPM Newsletter were based on the FDA’s Quality Mammography Standards as published on October 28 and November 10, 1997 in the Federal Register. These versions contained several mistakes which the FDA corrected in Rule printings that were distributed after the January/February issue of the Newsletter went to press. The following corrections should be made to the newsletter tables: submitted by: Priscilla Butler Washington, DC
TEST
IF FAILS
Evaluation of focal spot performance
The source of the problem shall be identified and corrective action shall be taken within 30 days of the test date.
AEC system performance
The source of the problem shall be identified and corrective action shall be taken within 30 days of the test date.
Breast entrance exposure (air kerma) and AEC reproducibility
The source of the problem shall be identified and corrective action shall be taken within 30 days of the test date.
Average glandular dose
The source of the problem shall be identified and corrective action shall be taken before any further exams are performed.
Darkroom fog
The source of the problem shall be identified and corrective action shall be taken before any further exams are performed.
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AAPM NEWSLETTER MANAGING EDITOR Marsha Dixon
EDITOR-IN-RESIDENCE Robert Dixon Send information to: Marsha Dixon Broadcast News Public Relations 201 Knollwood Street Winston-Salem, North Carolina 27104 (336) 721-9171 Phone (336) 721-0833 Fax Internet: brdcst@aol.com The AAPM newsletter is printed bi-monthly. Deadline to receive material for consideration is four to six weeks before mailing date. We welcome your entries, and encourage authors of articles to supply a photo. Please send material via e-mail, disks or mail. Faxes are encouraged as back-up, and are acceptable alone.
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April 10, 1998
May 15, 1998
AMERICAN ASSOCIATION OF PHYSICISTS IN MEDICINE One Physics Ellipse College Park, Maryland 20740-3846 (301) 209-3350 Phone (301) 209-0862 Fax e-mail: aapm@aapm.org http://www.aapm.org
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