Q1 2024 Urgent Caring- Editorials and Opinions: Urgent Care’s Future with POCUS – Better Care, Better Business

Tatiana Havryliuk, MD

At 6 p.m. on a busy Monday, 47-year-old Mr. Jones, whom you saw just three days prior, returns with persistent pain, redness, and swelling in his left axilla. Despite taking cephalexin, his condition has not improved. There is a 4 cm area of erythema, induration, and tenderness, but no fluctuance is evident. You contemplate whether incision and drainage for a suspected abscess is warranted. With some uncertainty, you proceed, but no pus is found. This scenario is not unique. In cases of soft tissue infections without a clear abscess, emergency physicians incorrectly predict the presence of a fluid collection 56% of the time [1]. Essentially, our physical examination is akin to flipping a coin.

Now, consider the possibility of placing an ultrasound transducer on the affected area to instantly determine if a fluid collection is present, as well as its depth and its size. For Mr. Jones, this tool would have confirmed the absence of an abscess, thereby averting a needless and painful procedure and conserving valuable time. 

Point-of-care ultrasound (POCUS) has been integral in enhancing diagnostic accuracy, increasing procedural safety, and expediting care in emergency departments for more than two decades. It is increasingly becoming a standard in primary care, and the Urgent Care community should welcome this technology.

Why is now the time to adopt POCUS?

• Affordability: POCUS devices are now more budget friendly. Handheld units range from $2,000 to $10,000, a significant reduction from the traditional cart-based systems priced at $20,000 and above.
• Supported by Evidence: There is abundant evidence showing how POCUS improves and expedites care. It’s backed by multiple medical organizations and is within the scope of practice of Urgent Care providers.  
• Value-Based Care: POCUS aligns with value-based care models, emphasizing overall cost savings. It aids in reducing unnecessary emergency department visits, more costly imaging, and repeat healthcare facility visits due to initial misdiagnosis or improper treatment.
• Technologist Shortage Mitigation: With a shortage of ultrasound and X-ray technologists, POCUS provides a cost-effective alternative.
• Revenue and Patient Volume: In a post-pandemic era, when patient volumes and revenue have decreased, introducing a new service like POCUS could attract new patients, broaden care for those with complex conditions, and generate additional revenue.

Which Common Urgent Care Presentations Could Significantly Benefit from POCUS?

• Soft Tissue Infections: POCUS excels in the evaluation of soft tissue infections, including detecting peritonsillar abscesses through intraoral and transcutaneous methods. [1-3]
• Respiratory Complaints: Lung POCUS can assess for pneumonia, pneumothorax, pulmonary edema, and pleural effusions with more sensitivity than chest X-ray. Plus, it avoids radiation exposure, which is vital for children and young adults. [4-6]
• Flank Pain, Urinary Retention, or Hematuria: Renal and bladder POCUS permits the evaluation of bladder volume and presence of hydronephrosis. A POCUS-first approach has been shown to reduce the need for CT scans in 60% of emergency department cases presenting with potential renal colic. [7]
• Upper Abdominal Pain: Biliary POCUS is effective for ruling out conditions such as cholecystitis or biliary colic.
• Lower Extremity Pain or Swelling: POCUS can be employed to exclude proximal leg deep venous thrombosis (DVT) using a compression technique, preventing unnecessary emergency department referrals. [8,9]
• Musculoskeletal Pain or Injuries: Evaluation of tendonitis, tendon ruptures, joint effusions, hematomas, and even fractures and dislocations can be accomplished with POCUS.
• Ocular Complaints: POCUS is highly accurate in identifying vitreous hemorrhage, retinal detachment, foreign bodies, and lens dislocation.
• Procedural Guidance: POCUS enhances the safety and efficiency of procedures such as difficult IV access, arthrocentesis, and shoulder dislocation reduction.

Additional Advantages of POCUS for Urgent Care Clinicians

Beyond enhancing patient care, creating extra income, and attracting more clients, POCUS offers numerous benefits including:

• Facilitating patient education about their health conditions.
• Ensuring patient adherence to imaging.
• Elevating the overall patient experience.
• Enabling clinicians to make more educated decisions.
• Equipping clinicians with a valuable and marketable skill.

What Is the Return on Investment?

Adopting a POCUS program necessitates an initial investment in ultrasound equipment, an image storage solution, and a training program for medical staff. After achieving proficiency (within 6 months to a year), POCUS procedures can be billed similarly to other medical services, utilizing specific CPT codes for “limited ultrasound.” [10] Ensure that your insurance contracts cover POCUS. Medicare reimbursement rates for POCUS range from $56 for lung ultrasounds to $117 for DVT ultrasounds. The potential for significant additional income exists depending on patient volume, types of cases, imaging capabilities, and payor mix.

For instance, based on 2024 nationwide Medicare rates, performing approximately 45 POCUS exams monthly (1.5/day) could yield an additional billable amount of $37,000 annually. Consider using a POCUS ROI Calculator to get a more precise approximation of POCUS revenue for your practice. [11]

For Urgent Cares with Flat-Rate Contracts

In situations with flat-rate contracts, POCUS services are integrated into the patient visit charge. Nonetheless, POCUS can still boost revenue by building patient loyalty and attracting new patients. [12]

So, What’s the Bottom Line?

POCUS has proven to enhance and expedite the delivery of care in emergency departments and primary care settings. The devices are now affordable, and training is more accessible. It is well within the scope of practice of Urgent Care providers. It can help manage common Urgent Care presentations, such as respiratory and soft tissue infections, with more precision and better patient outcomes. With appropriate training and workflow, it’s time for POCUS to be integrated into Urgent Care.

About the author:

Dr. Havryliuk is an emergency physician with over 15 years of clinical POCUS experience, past Emergency Ultrasound Director at Brooklyn Hospital in NY. She is on the mission to empower clinicians with POCUS to take better and more efficient care of their patients. 

LinkedIn: https://www.linkedin.com/in/tatiana-havryliuk-md/

Email: tatiana@hellosono.com

References:

1. Tayal VS, Hasan N, Norton HJ, Tomaszewski CA. The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department. Acad Emerg Med. 2006;13(4):384-388. doi:10.1197/j.aem.2005.11.074
2. Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012;19(6):626-631. doi:10.1111/j.1553-2712.2012.01380
3. Rehrer M, Mantuani D, Nagdev A. Identification of peritonsillar abscess by transcutaneous cervical ultrasound. Am J Emerg Med. 2013;31(1):267.e1-267.e2673. doi:10.1016/j.ajem.2012.04.021
4. Ticinesi A, Lauretani F, Nouvenne A, Mori G, Chiussi G, Maggio M, Meschi T. Lung ultrasound and chest x-ray for detecting pneumonia in an acute geriatric ward. Medicine (Baltimore). 2016 Jul;95(27):e4153. doi: 10.1097/MD.0000000000004153. PMID: 27399134; PMCID: PMC5058863.
5. Pirozzi C, Numis FG, Pagano A, Melillo P, Copetti R, Schiraldi F. Immediate versus delayed integrated point-of-care-ultrasonography to manage acute dyspnea in the emergency department. Crit Ultrasound J. 2014;6(1):5. Published 2014 Apr 27. doi:10.1186/2036-7902-6-5
6. Baid H, Vempalli N, Kumar S, et al. Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study. Int J Emerg Med. 2022;15(1):27. Published 2022 Jun 13. doi:10.1186/s12245-022-00430-8
7. Adhikari S, Amini R, Stolz L, et al. Implementation of a novel point-of-care ultrasound billing and reimbursement program: fiscal impact. Am J Emerg Med. 2014;32(6):592-595. doi:10.1016/j.ajem.2014.02.051
8. Mumoli N, Vitale J, Giorgi-Pierfranceschi M, et al. General Practitioner-Performed Compression Ultrasonography for Diagnosis of Deep Vein Thrombosis of the Leg: A Multicenter, Prospective Cohort Study. Ann Fam Med. 2017;15(6):535-539. doi:10.1370/afm.2109
9. Hannula O, Vanninen R, Rautiainen S, Mattila K, Hyppölä H. Teaching limited compression ultrasound to general practitioners reduces referrals of suspected DVT to a hospital: a retrospective cross-sectional study. Ultrasound J. 2021;13(1):1. Published 2021 Feb 2. doi:10.1186/s13089-021-00204-y
10. “2024 Medicare Fees for Diagnostic and Procedural POCUS for Urgent Care Centers.” Accessed: Feb. 1, 2024. [Online] Available: https://www.hellosono.com/downloadables-1/urgent-care-2024-fees-pocus-exams
11. “Are you leaving revenue on the table?” POCUS ROI Calculator. Accessed: Feb. 1, 2024. [Online] Available: https://www.hellosono.com/pocus-roi-calculator
12. Andersen CA, Brodersen J, Rudbæk TR, Jensen MB. Patients’ experiences of the use of point-of-care ultrasound in general practice – a cross-sectional study. BMC Fam Pract. 2021;22(1):116. Published 2021 Jun 18. doi:10.1186/s12875-021-01459