title: Pediatric Echocardiography by Work Relative Value Units: Is Study Complexity Adequately Captured?
abstract: Present resource-based relative value unit (RVU) assignment for echocardiography is based on Current Procedural Terminology (CPT) codes, which do not incorporate complexity of diagnosis, time spent for image acquisition, or interpretation of echocardiograms. The objective of this study was to determine whether CPT-based RVU assignment accurately reflects physician effort in performing and interpreting pediatric echocardiographic examinations.
  
  
  
  Cardiac complexity category (CCC) and physician time for study interpretation of 123 echocardiograms (June to September 2013) were prospectively assigned. Categories included (1) focused effusion/function evaluation, (2) normal anatomy/focused preterm infant studies, (3) acquired heart disease, (4) congenital heart disease excluding single ventricles, (5) single ventricles including heterotaxy syndrome, and (6) hearts on mechanical support. Subsequently, a random sample of echocardiograms (March to August 2013) were retrospectively analyzed, and each study was assigned a CCC and an extrapolated median interpretation time (MIT) on the basis of prospective data collection. Assigned work RVUs based on CPT codes were recorded. Comparisons were made between CCC and time for study interpretation, work RVUs, number of images acquired, and total scan time.
  
  
  
  A total of 933 echocardiograms were analyzed: 198 (21%), 174 (19%), 98 (11%), 359 (35%), 84 (9%), and 20 (2%) studies in CCCs 1 to 6, respectively. Total scan time, MIT, number of images, and work RVUs were different among CCCs (P < .0001). However, among the more complex studies (CCCs 2-5), work RVUs were similar, while number of images obtained and MIT were different (P < .001). Correlation analysis showed no association between work RVUs and CCC, total scan, or number of images per study. Compared with older patients, work RVUs of studies in children <2 years of age were lower, while all other markers of study complexity were higher (P < .05).
  
  
  
  Current CPT-based assignment of work RVUs does not discriminate study complexity and physician effort. The results of this study highlight the need for a refined system that accurately assesses physician effort in pediatric echocardiography.
authors.affiliation: Division of Cardiology, Department of Pediatrics, Stanford Children's Health, Stanford, California. Electronic address: sbalasubramanian@stanford.edu.
authors.forename: Sowmya
authors.initials: S
authors.lastname: Balasubramanian
authors.affiliation: Division of Cardiology, Department of Pediatrics, Stanford Children's Health, Stanford, California.
authors.forename: Alaina K
authors.initials: AK
authors.lastname: Kipps
authors.affiliation: Division of Cardiology, Department of Pediatrics, Stanford Children's Health, Stanford, California.
authors.forename: Shea N
authors.initials: SN
authors.lastname: Smith
authors.affiliation: Division of Cardiology, Department of Pediatrics, Stanford Children's Health, Stanford, California.
authors.forename: Theresa A
authors.initials: TA
authors.lastname: Tacy
authors.affiliation: Division of Cardiology, Department of Pediatrics, Stanford Children's Health, Stanford, California.
authors.forename: Elif Seda
authors.initials: ES
authors.lastname: Selamet Tierney
mesh_terms: D000293:Adolescent; D000328:Adult; D002140:California; D002648:Child; D002675:Child, Preschool; D039702:Current Procedural Terminology; D004452:Echocardiography / Q000145:classification* / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010372:Pediatrics / Q000145:classification / Q000706:statistics & numerical data*; D015895:Relative Value Scales; D016526:Workload / Q000145:classification* / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Cardiac complexity; Congenital heart disease; Pediatric echocardiograms; Physician effort; Work relative value units