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Sports medicine providers increasingly perform musculoskeletal (MSK) and sports ultrasound (US) but struggle to optimize revenue from these interventions.1 The growing use of US in clinical practice uncovers tensions among payers and health systems regarding necessary training and credentialing, as well as the quality of evidence for its use, resulting in inconsistent coverage and reimbursement across different insurance carriers and challenges in physician revenue management. Use of sports US is well supported in current literature. But, US training pathways, existing billing codes for US use, and common pitfalls in billing require further examination, especially after the 2015 Centers for Medicare and Medicaid Services (CMS) changes that have streamlined joint injection billing practices but left ambiguity around non-joint injections. This review summarizes the current landscape and offers potential solutions for payers, providers, and regulators to address current challenges and growing controversies. Primary care sports medicine physicians are fellowship-trained physicians from physiatry, family medicine, pediatrics, internal medicine, and emergency medicine. Primary care sports medicine physicians, as well as residency-trained physiatrists, rheumatologists, radiologists, physical therapists, chiropractors, physician assistants, and nurse practitioners, often perform MSK and sports US. However, training is variable depending on the specialty and experience of the clinician. Many, but not all, providers learn MSK and sports US through commercial courses outside of required training for licensure and board certification while medical schools and residency training programs are increasingly implementing point-of-care US curricula that include MSK components. Primary care sports medicine physicians complete a 1-year full-time fellowship in sports-related care, including in-depth MSK and sports US, as an Accreditation Council for Graduate Medical Education requirement using recommendations from the American Medical Society for Sports Medicine and American Institute for Ultrasound Medicine. This required US training includes significant diagnostic and interventional MSK and sports US volume,2, 3 with rigorous standards upheld via exam supervision and standardized testing supported by various medical specialty boards. To supplement their training, many sports medicine clinicians, for a variety of reasons, opt to pursue additional third-party certification or accreditation in MSK sonography (Registered in Musculoskeletal Sonography or American Institute for Ultrasound Medicine) with their own criteria of exam volume, standardized testing, and ongoing continued medical education. Physicians trained in physiatry, rheumatology, and MSK radiology have similar requirements supported by their respective boards and some opt for similar additional third-party certifications or accreditation. Importantly, inconsistencies exist regarding adequate training and certifications to appropriately bill for US services and ensure patient safety in both diagnostic and interventional capacities. There is currently no established consensus for fellowship-trained sports medicine physicians to certify their skills, but health systems require organizational leadership attestation for competency and credentialing. For those without formal longitudinal training, the standard is even more nebulous, although some insurance carriers or health systems accept completion of commercial ultrasound courses or additional certification such as Registered in Musculoskeletal Sonography accreditation. To maintain patient safety and acceptable clinical outcomes, significant efforts are needed to discern who may appropriately perform and bill for MSK and sports US services. Diagnostic US and ultrasound-guided (USG) procedures are increasingly common in primary care and specialty practice settings, but there is ambiguous guidance provided for the most cost effective and clinically appropriate application of these services. Specific Current Procedural Terminology (CPT) codes are required to effectively bill for ultrasound services, as well as professional and facility reimbursement. The update in 2015 from CMS added CPT codes 20604, 20606, and 20611 to capture USG small, medium, and large joint/bursae injections which most clinicians now use.4 Historically, 76942 is a CPT code used for US guidance in interventional procedures without a specific anatomical site, often applied in addition to relevant CPT codes for peritendinous and/or miscellaneous injections.5 Currently, 76881 and 76882 are the most applicable CPT codes for diagnostic sports US, representing complete and limited assessments, respectively. Clinicians report confusion with use of CPT code 76942 (US guidance for needle placement) following the 2015 CMS update introducing CPT codes 20604, 20606, and 20611 for joint or bursa injections under US guidance.7 CPT code 76942 is now reserved for injections and aspirations not captured by the codes for USG small, medium, or large joint/bursae injection (CPT codes 20604, 20606, and 20611, respectively), including peritendinous injections, ganglion cyst aspirations, and other non-joint/bursae injections as the existing CPT codes for these procedures (ie, 20550, 20551, and 20612) do not include US guidance. Despite the authors finding sufficient research justifying increased accuracy, private insurers commonly reject coverage for CPT code 76942 when US guidance is used, even if the corresponding and most applicable procedural code does not include US guidance. For example, insurers may limit reimbursement to solely CPT code 20550 for a USG proximal biceps tendon sheath injection. Current reimbursement structures (Table 1) and practices may incentivize clinicians to instead perform landmark-guided (LG) procedures, jeopardizing quality of care in exchange for procedural speed, procedural volume, and higher patient loads.1, 8, 9 Although there may be clinician-directed incentive to perform LG injections whether for reimbursement or expediency, hospital-based outpatient facilities and ambulatory surgical centers may be incentivized to have USG injections performed given potentially higher reimbursement rates in some geographies. Providers should note facility reimbursement may vary depending on the practice setting, which in turn may affect professional reimbursement. $52.40 0.66 wRVU $80.87 0.89 wRVU $53.37 0.68 wRVU $87.34 1.00 wRVU $63.40 0.79 wRVU $96.39 1.10 wRVU $56.61 0.75 wRVU $85.72b 1.42 wRVUb $55.96 0.75 wRVU $85.07b 1.42 wRVUb $63.72 0.70 wRVU $92.83b 1.37 wRVUb $51.75 0.90 wRVU $62.43 0.69 wRVU $29.11 0.67 wRVU Providers have reported confusion regarding how to bill when the most applicable code such as 20550 does not include US guidance. One potential solution drawing on CMS guidance is documentation of medical necessity for using US guidance when applying CPT code 76942, highlighting needle placement for accuracy, avoidance of iatrogenic injury, and minimizing patient discomfort. In addition, retrievable imaging, provider competency verification, and documentation of the diagnostic or interventional procedure should be readily available to counter insurance coverage deficiencies. Emerging evidence suggests USG injections may offer cost-effectiveness over alternative interventions in certain clinical scenarios.10, 11 Beyond improved accuracy, USG injections relative to placebo and/or LG injections may be associated with decreased intraprocedural pain,12 decreased post procedural pain at follow-up,9 and improved function.13 Adding CPT code 76942 for US guidance to CPT codes that are not captured in the current structure will reflect the appropriate clinical time and expertise required to improve patient outcomes. Still, further research is needed to assess the efficacy of USG compared to LG injections in terms of avoiding surgery, patient satisfaction, and return to play timelines. Diagnostic US CPT codes (76881 or 76882) when billed in the same visit as USG procedures are not typically covered by insurance carriers. The result is that many practices choose to perform diagnostic US on the first visit for comprehensive evaluation and subsequently have patients return for a separate procedural treatment visit, if indicated. The authors find the most common barriers preventing completion of diagnostic US and USG interventions at the same visit are lack of reimbursement and limited total visit time rather than access, equipment, or supply availability. Frequently, the total visit time allocated is insufficient to complete all necessary steps of an initial visit, diagnostic exam with US evaluation, treatment plan development, and safe performance of an USG procedure. The availability and ease of a separate future scheduled visit gives sports medicine providers time to adequately prepare for the safest possible intervention and allows the patient time to truly evaluate their risks, benefits, and alternatives. Conversely, the administrative decision for USG procedures performed on a distinct visit may result in larger financial and access burdens for patients, unnecessary expenses for insurers, increased administrative burden for medical practice billers, and higher patient load for clinicians, further straining the heavily-taxed health care system and promoting provider burnout.14 Furthermore, sports medicine clinicians should be aware that Medicare guidance explicitly discourages having patients return for an isolated procedure visit on the same region in which diagnostic US was performed for revenue capture purposes.15 Potential mitigation strategies include advocacy efforts directed toward insurance coverage and reimbursement for same-visit diagnostic and interventional US services to remove barriers and offload burden for patients, providers, and health care systems. CMS provides vague guidance on what constitutes a complete (76881) versus limited (76882) diagnostic US exam, resulting in inconsistent coverage or reimbursement even if comprehensive diagnostic US evaluation had been performed. Consensus criteria for CPT codes 76881 and 76882 remain controversial as compensation amounts for each continue to be variable. Currently, only professional organizations have published specific recommended diagnostic US benchmarks defining complete evaluation.3 Potential solutions include development of refined and standardized US criteria that explicitly clarify the minimum requirements to qualify for complete diagnostic US reimbursement, endorsement of specific criteria from most insurance carriers, and consistency in reimbursement amounts across insurance payers. Sports US is becoming an increasingly omnipresent tool supporting sports medicine and other allied health care providers. However, inconsistent training requirements, outdated billing codes, and ambiguous guidance are barriers to accessible and appropriate patient care.1 These inefficiencies disincentivize the use of US, which has been shown to improve patient experience and outcomes.12, 13 Aligning training certification and billing practices with clinical realities will reduce barriers for physicians seeking to incorporate diagnostic and interventional US and enhance the overall patient experience and outcomes. The authors thank Jonathan Finnoff, DO and Carly Day, MD for support in manuscript development and review. Drs Pomerantz, Gay, Cardoos, and Reed have no conflicts to disclose. Dr Hu discloses consulting fees received from Pacira Biosciences, Inc., Apex Biologix, LLC., GE Healthcare, LLC. and Best in Class MD, Inc. He additionally discloses honoraria from MSKUS, Inc., the American Medical Society for Sports Medicine, and the American College of Sports Medicine, along with an unpaid board of director position with the American Medical Society for Sports Medicine. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.