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How is PET/CT different from traditional PET imaging?

Posted on: 10.12.17

Today, most of the Positron Emission Tomography (PET) scanners you find in hospitals, or delivered via mobile imaging, are actually PET/CT cameras. Modern PET/CT scanners combine both PET and Computed Tomography (CT) scans almost simultaneously to provide a greater amount of clinical data to assist in the diagnosis process.

Combining the benefits of PET and CT

A PET/CT scan includes two parts: a PET scan and a CT scan. The CT portion of the scan produces a 3-D image that shows a patient’s anatomy. The PET scan demonstrates function and what’s occurring on a cellular level. The PET scan is unique because it images the radiation emitted from the patient while the CT records anatomical x-rays, showing the same area from another perspective.

The role of attenuation correction

PET/CT scans not only pinpoint localization; they also offer significant help with attenuation correction, a huge advantage. During a CT scan, the system records numbers, called Hounsfield units, which measure the density of the tissue that it travels through. Not only does the CT produce images, but they also have numbers assigned to each individual pixel.

The PET scan measures the level of radiation coming from the patient and compiles information that the system needs to decipher. It uses algorithms and corrections, including the Hounsfield units from the CT scan, and adjusts the images in accordance with the corrected densities for each region.

In the 1990’s or early 2000’s, a PET-only scan would have used a transmission scan for attenuation correction or forgone it completely. Today, however, there is better technology available. Using both CT and PET to cross-check data and corroborate each other is a way to increase confidence and reduce guesswork. It gives significantly more data points to reference in order to determine a diagnosis and treatment plan.

PET/CT is more than just oncology

One of the biggest misconceptions about PET/CT is that its benefits are limited to diagnosing cancer. There are many new uses that are benefiting from PET/CT technology that fall outside of oncology. For example, in neurology, a brain CT or MRI only looks at the structure. The benefit of looking at function through an FDG-PET scan is that a functional change on the cellular level will be seen before a possible structural change. The same can be said for cardiac imaging, epilepsy, Alzheimer’s disease, dementia, infection and inflammation and a host of others. These are areas that could benefit from taking advantage of the advancements in the PET/CT world.



How to reduce your dose with SPECT MPI studies

Posted on: 10.05.17

Advancements in medical imaging technology have revolutionized health care, allowing doctors to more accurately diagnose disease using SPECT for MPI scans. Any time a physician orders an imaging scan, however, there is always concern about the level of radiation exposure.

ASNC and SNMMI are raising the bar with their guidelines, and the industry as a whole is moving toward a low dose standard. What does that mean and how will that change impact your practice? Here are some resources that will help you better understand and adopt a low dose protocol.

Implementing a low-dose protocol (link)

If you are considering the implementation of a low-dose protocol, you’ll need to evaluate three important elements within your practice: proper patient segmentation, commitment, and technology.

Patient Segmentation

Proper patient segmentation is a large part of implementing a low-dose protocol because each patient is a unique combination of age, weight, shape and medical history. Did you know that ASNC estimates half of the patient population falls under the appropriate criteria for low-dose? Following the ASNC guidelines can help physicians decide when to reduce radiation exposure in order to optimize patient care.

Commitment

It only takes one physician to publicly advocate low-dose imaging to get the conversation started. With this progressive thinking, however, your practice will have to collectively adopt a new low-dose culture. The physicians, both referring and reading, must be committed to a low-dose protocol in order to successfully implement the change. It will require further education, training, leadership, discipline and diligence along with a “can-do” attitude from all parties.

Technology

With a low-dose protocol, the goal is to acquire an image with sufficient quality for maintaining diagnostic accuracy. Maintaining image quality while reducing the patient dose is a challenge, but new technology makes it possible. A multi-head camera, combined with nSPEED reconstruction software and Tru-ACQ Count Based Imaging provides fast acquisition times with the lowest appropriate dose.

TruACQ Count Based Imaging™ is the first and only count-based SPECT imaging technique that ensures consistent counts for every patient study, regardless of the patient’s size, weight, or the dose used. The proprietary software is designed to simplify the decision-making process around acquisition time. TruACQ™ takes a quick look at exactly what the detectors are picking up, which accounts for all possible variables, and provides the optimal scan time for the patient being

Stress-Only Protocol (link)

Another way to help lower the radiation burden to patients is to adopt a stress-only protocol. Stress-only protocol is the directive by which a medical provider performs a cardiac stress test without the complementary resting scan. Traditionally, both a resting scan and a stress scan are performed on patients, which are then compared to more confidently support a diagnosis. Often, what could potentially be an abnormality in one image is disproved by the other, thereby reducing inaccurate conclusions. It does, however, subject the patient to two radiation doses, sometimes unnecessarily.

Those with a low probability of heart disease, typically younger patients who have limited risk factors, are the ideal candidates to forgo the resting scan and follow the stress-only protocol. Not only does the protocol support the global drive to decrease the radiation burden to patients, it also reduces costs, and saves time.

Easing concerns (link)

The word radiation may stir-up heightened concerns, especially if a patient is having multiple tests performed. How much radiation is considered safe and over what time period? Do some tests bring greater exposure than others? At what point should they become concerned? These are all valid questions. The bottom line is that medical imaging is a safe, painless, and cost-effective way to diagnose and treat disease.

Is there a real risk?

Any medical procedure can have side effects, but when the procedure offers useful clinical information that will help your physician decide on your treatment, the benefits of the procedure far outweigh its very small potential risk.

The decision to implement a low-dose protocol is an important step for both you and your patients. Keep in mind that not every patient is required to be low-dose for your practice to be considered a low-dose lab. In the end, it’s about lowering the radiation burden to your patients more than you are now.



Best practices for coding nuclear medicine scans

Posted on: 07.27.17

In recent years, billing for nuclear scans as it relates to coding, has been modified to more accurately reflect the provider services and thus, reimbursement for patient care. We are finding, however, that in internal medicine offices or cardiology groups, where there would likely be fewer conversations about these changes than in a nuclear practice, more clarification may be needed.

Decoding the billing code process

To be clear, the coding itself has not changed, but who can use designated codes have changed. Medicare is very specific as to the way in which they require the submission. The most confusion comes with the series 93015 through 93018 codes. With any test, there’s a differentiation among whether you supply the equipment, supervise the procedure, or interpret the report. Billing for anything other than your specific function, especially when it pays a higher fee, leads to non-compliance and possibly additional scrutiny via an audit. These are typically innocent mistakes that can lead to much larger issues. With that in mind, here is a list of basic codes for billing MPI SPECT that may be helpful:

  • 78452 – Multiple Myocardial Perfusion Imaging, at stress and at rest. This code should only be billed once.
  • A9500 – The “A” series codes relate to radiopharmaceuticals. A9500 represents Technetium tc-99m sestamibi, diagnostic. This is a per study dose and should be billed for 2 units. If sestamibi is used, bill NDC code 65857-0500-05.
  • J0153 – The “J” series codes describe drugs. J0153 represents an injection of adenosine – this should be billed 1 unit for each milligram. You might also use J2785, an injection of Lexiscan and should be billed for 4 units.
  • 93015 – This is the global code for cardiovascular stress testing. 93015 should only be used if your practice owns the stress equipment and your physician can interpret the test and issue the report.
  • 93016 – The second in the cardiovascular stress test series, this code should be used if you provide supervision only, without interpretation or report.
  • 93017 – The third in the cardiovascular stress test series, this code should be used if you provide tracing only, without interpretation or report.
  • 93018 – The fourth in the cardiovascular stress test series, this code should be used if you provide interpretation and report only, without supervision.

Using the correct codes is critically important for accurate reimbursement. Knowing which codes to use and why helps increase overall compliance and, above all, properly reflects the procedure that was performed.



What is Fluorescence Attenuation Correction?

Posted on: 07.20.17

Attenuation correction is a process that identifies and corrects for soft tissue artifacts in SPECT images. Ultimately, the goal is to minimize the visual impact of attenuation in order to provide images that more accurately portray the distribution of imaging agent in the patient. This results in higher reading confidence, improves diagnostic accuracy, and lowers the incidence of false positive studies thereby reducing the number of unnecessary diagnostic cardiac catheterizations.

Traditional attenuation correction methods

Historically, there were two primary methods of attenuation correction, line source, and CT. While line source attenuation correction is a valid method and is still currently used, its biggest disadvantages include the challenging number of mechanical failures, the difficulty of use, line source decay yields imaging quality issues as a function of time and has expensive replacement cost. For these reasons, users often opt for an alternative method when it’s time to consider replacing or upgrading equipment.

CT attenuation correction is a popular method primarily used in the radiology and oncology fields where the CT can be used for diagnostic purposes. However, for a dedicated cardiac environment, the high cost of a SPECT-CT system is unsustainable. Additionally, the costs of constructing a shielded room can be greater than the scanner itself.

The lack of viable options for Cardiologists has resulted in patients being without the benefit of attenuation correction. However, Cardiologists who want to offer attenuation correction are leveraging a new, third method – Fluorescence Attenuation Correction.

Fluorescence Attenuation Correction – Low dose and low cost

Fluorescence attenuation correction utilizes a fluorescence X-ray thus allowing for a lower dose and less radiation exposure to the patient. The method is a unique combination of hardware and software technology that allows for the delivery of superior image quality at the lowest possible radiation burden (less than 5 microsieverts).

From a cost standpoint, FAC does not require room shielding and uses the same detectors as the SPECT system. The homogenous pattern of the fluorescence X-ray also contributes significantly to a better, cleaner image and substantially increases diagnostic confidence.

Currently, fluorescence attenuation correction is only available in conjunction with the Digirad X-ACT+ camera. Although attenuation correction is not new to the industry, Digirad’s methodology is able to offer a significant improvement from a reliability, exposure and cost standpoint. The X-ACT+ uses an optimized design to bring benefits of attenuation correction to the cardiac patient, physician, technologist, and facility. The end result is more accurate results, less false positives, and less needless additional testing which means less radiation burden for patients and lower costs to the payer systems.



Three reasons hospitals use provisional CT, MRI, or PET Imaging

Posted on: 04.20.17

Most hospitals offer CT, MRI, and PET imaging services in-house, but there are times when bringing in a mobile imaging service on a provisional basis makes more sense.

What is provisional imaging?

In traditional mobile imaging, a technologist visits the hospital or clinic on a weekly basis and transports the equipment back and forth with each visit. With provisional imaging, the equipment is left at the facility for a longer period of time, typically three to six months or more. Hospitals may choose this service option for a number of reasons:

1. Remodeling the CT imaging space or purchasing a new camera

One of the most common reasons a facility may choose provisional mobile imaging is in the case of new equipment or a space remodeling project. The remodeling process requires careful planning so as not to interrupt your current service. In the best-case scenario, your service may be inoperative for a few weeks due to construction, and any unforeseen delays could potentially add to that timeline.

Planning ahead and having a provisional mobile imaging service in place is a simple way to avoid inconvenient and costly disruptions. Be sure to start the process early in order to increase the likelihood that you’ll be able to secure the ideal system and configuration for your needs.

2. Long term CT machine repairs

Another popular reason to utilize provisional service is lengthy equipment repairs. When a CT, MRI, or PET imaging system is in need of extensive repairs, a hospital cannot simply stop imaging. Sometimes repairs may only take a day or two, but there are other instances when repairs are significant and can require significantly more time to fix. Waiting on ordered parts or an available service engineer can leave you down for weeks. In this case, utilizing a provisional service is a way to fill the gap while your equipment is brought back online.

3. Bring down a backlog

Lastly, there are times when hospitals simply face a backlog of imaging needs. Regardless of the reason, if volume increases and your current equipment and number of technologists cannot effectively manage the workload, you’re faced with determining the best method of working through the challenge. Bringing in a CT, MRI, or PET imaging system on a provisional basis is not only a way to get out from under the backlog, but it’s also a smart way to determine if this is a trend that needs to be addressed with a more permanent solution.



Should I buy a nuclear camera or use a mobile service?

Posted on: 03.30.17

The choice between purchasing a nuclear camera or using a mobile service is an important decision for your practice. There is a broad range of factors that shape the decision, and following a “cookie cutter” formula is not recommended. Understanding the unique dynamics at work in your practice can shed light on which choice is best for you and your patients. Let’s explore some key data points to review:

Study volume

Study volume is an important metric when considering purchasing a nuclear camera vs. contracting with a mobile provider. On the low end, 60 studies per month could technically support camera ownership, but a monthly average of 120 is a more sustainable number. Below 100 studies per month becomes financially challenging and requires temporary staffing and other hybrid approaches to make the best of things. Another way to evaluate the volume question is on the number of days in the week in which you scan. Practices that prefer imaging less studies per day and more days per week will find a need for creativity in managing their non-equipment costs in order to achieve reasonable profitability from their Nuclear Lab.

Established practice vs. start-up

Often, your prior experience can be a contributing factor in the decision. If you’ve owned a camera in the past and understand the requirements, it’s easier to know if ownership is a right fit. If you are starting up a practice, you could initially opt for a mobile service to get a better feel for your study volume before making a major purchasing decision. Given all of the various start-up expenses, including needing cash in the bank to fund the lag between your open day and cash flow back from the various payors, whether or not you want to tie up cash or credit resources for a major purchase is a critical decision point. Physicians who open a smaller 1 to 4 provider practice, versus a multi-physician practice, often choose mobile services over ownership for the similar reasons.

The value of the unknown

One major factor that complicates the decision is clarity on the actual cost burden or potential profitability when purchasing a camera. Because mobile services typically use per-day or other similar billing options, your financial risk is very low, and the practice has a very clear understanding of profit overall, and per day of service. Since camera costs (lease payment or depreciation plus repair and maintenance) are not the highest cost drivers, thinking that ownership is more profitable than a service is not a given. With pending insurance reimbursement changes, new payment models on the horizon, and the reality of appropriate use criteria, it’s difficult to know the exact financial return you can achieve from a camera purchase.

The question of how to provide imaging services touches on a full spectrum of factors including revenue, profitability, patient convenience, market perception, practice size, and patient satisfaction. The final decision is shaped by your study volume and how established your patient base is, but ultimately it comes down to how comfortable you are with the requirements of running a nuclear lab and your willingness to invest the time and energy into managing on your own.



6 tips for keeping your nuclear lab profitable

Posted on: 02.02.17

Nuclear laboratories in physician offices and hospitals require expensive equipment, trained staff, plus the costs of isotopes and other pharmaceuticals. These factors may be major contributors to a lab’s costs, but there are many other opportunities to consider for increasing the bottom line.

Here are six tips that can make a big difference in the profitability and efficiency of your nuclear lab:

1. Lab space

Consider the size of your current lab space. Is it larger than it needs to be? New equipment often requires a smaller footprint and the updated technology would likely allow you to accommodate higher patient volume. Reconfiguring your space may also provide the square footage you need to create an additional exam or procedure room. While decreasing space can save money, increasing the number of patient services delivered in the same amount of space will also lead to increased profits.

2. Licensing and Compliance

The costs associated with licensing and safety compliance are ongoing expenses in both time and manpower. Are you using the right efficiencies in maintaining them? For example, if compliance audits are required twice per year, why perform a third?

Consider the effective use of your workforce. Is your highest paid employee spending hours each month maintaining safety requirements? You could save money by outsourcing that work or allocating it to a less expensive employee. Be sure your employees’ job responsibilities and the tasks they’re performing are in line with the skill sets their salaries warrant.

Also, if you are a Radiation Safety Officer for your practice or multiple practices consider how much time you spend on these functions. From a profitability standpoint, how much revenue productivity are you missing while performing those tasks? Most physicians know their average revenue per hour and it is likely to be significantly more than outsourcing RSO duties and/or outsourcing the Radiation Safety Program. In terms of personal life, a physician taking on these tasks “after hours” may be pleasantly surprised at the benefit of investing just a few dollars in order to spend more time with family and friends. Though it’s hard to put a price on work-life balance, outsourcing these functions is a fairly inexpensive proposition.

3. Costs of consumables

Band-Aids, cotton balls, IV tubes, Derma tabs, saline, and more…these incidental costs can add up to $10 – $20 per patient, per procedure. Does your practice have a protocol that maximizes the efficiency of these items? Reducing costs from $20 to $10 per patient seems insignificant until you realize that a $10 savings for a volume of 5,000 scans per year increases profitability by $50,000. That’s a significant savings and a substantial impact to your bottom line.

You should also consider the prices at which you’re purchasing these items. Are you getting the best price available? Market resources including buying groups and industry consortiums can be beneficial to decreasing the overall costs of these items.

4. Maximize the patient experience

There’s no question that patients appreciate efficiency too. Are you optimizing patient protocols in order to keep the length of their visit to a minimum? Do they leave your office feeling they’ve had a positive patient-centric experience that was equally respectful of their time?

Consider the patient whose four-hour appointment could have easily taken three hours. This not only increased the office resources consumed by the patient, but you’re risking the chance that the patient will search for another office the next time. After all, they need to find a more efficient use of their time as well.

5. Efficient scheduling

Optimizing the practice’s scheduling can make a significant difference in both income and costs to the practice. For example, if Tuesday requires overtime costs for lab techs and front office staff and Wednesdays sees only 60% volume, both have negatively impacted the bottom line.

Patient no-shows can also be detrimental to your profitability. How does your practice minimize no-shows? We’ve recommended educating patients about the materials used for their test––like isotopes, for instance. Before their appointment, the patient should be well aware that the materials are individually ordered and cannot be used on the next patient if they miss their appointment. You also might consider holding a monthly gift card drawing for patients who kept their appointments as a simple way to say thanks. Check out more ideas here.

6. Re-evaluate over time

To understand profitability, think like an accountant. If that’s not your strong suit, consider appointing someone within the practice — or even outsourcing this function — to help you optimize the profits for your practice.

As in any business, variables change and it’s important to re-evaluate them on a regular basis. Managing profitability is an ongoing process so be sure to continually monitor checkpoints and make adjustments when necessary. The ultimate success of your practice will depend upon it.



Proper comparison is key when considering supine vs. upright imaging

Posted on: 01.19.17

Cardiologists and their patients are learning more than ever about the benefits and limitations of supine vs. upright positioning for nuclear diagnostic imaging. While horizontal, face-up scans taken while patients are lying flat is the traditional method, upright imaging is a well-established method that has gained popularity, most likely due to the comfort and ease of use it offers to both the patient and the technologist.

Proper comparison is the key

Although both approaches have pros and cons, the key to proper image analysis is the comparison with a system-matched, multi-site, low-likelihood normals database. Due to the differences in anatomic distribution of potential sources of artifacts, quantification of the two methods will vary by gender, and by imaging convention (upright or supine). There may also be differences in system resolution, collimation, acquisition, and processing protocols including reconstruction algorithms, as well as filtering approaches and choices required for imaging. When using a normals database for comparisons, one must be certain to use a database of true comparables with regards to these variables. The normals database should include separate images for male and female anatomies.

A matter of patient comfort

Clinically, choosing one position over the other does not impact the imaging results. Physicians are finding confidence with both methods. There are some distinct differences, however. When in the supine position, patients are instructed to lie completely still with their arms above their head. Unfortunately, some patients, particularly those with shoulder or arm impediments, find this especially uncomfortable and a difficult position to hold. Also, it’s necessary for the scanners to be close to the patient’s head and face, which may bring on the feeling of claustrophobia.

In contrast, in the upright position, patients are seated with their arms rested on the device’s armrest, which is a much more natural and comfortable position. The camera’s detectors are much less imposing, providing significant improvement in comfort, and may help lower the patient’s anxiety level. These comfort-centric advantages often improve patient compliance, leading to minimal patient movement, which reduces motion artifacts in the final images.

Position change leads to reading ease

In the supine position, where the patient is lying down, versus the upright position, where the patient is sitting in a chair, the patient’s organs will settle differently. For example, when a patient’s arms are raised in the supine position it can cause a shift in the diaphragm, which, in some cases, may obstruct a clear view of the heart. In this instance, upright imaging offers the benefit of allowing the technologist to center the heart in the field-of-view, without extending the torso, thus keeping the diaphragm lower, and reducing the potential for diaphragmatic artifacts.

Therefore, parallel comparison is key: Supine patient studies should be scored against a normals database created with studies acquired on a supine system; upright patient studies should be compared to a normals database created with studies from an upright system.



Digirad’s Top 5 Blog Posts from 2016

Posted on: 01.12.17

Digirad’s blog provides a variety of resources that keep you up to date on the ever-changing healthcare industry, including the advancements and issues that directly impact the operation of your practice. As we kick off a new year, here’s a look back at Digirad’s Top 5 Blog Posts from 2016:

5. Section 179 tax savings medical equipment

In today’s competitive environment, it’s important to continually reinvest in your practice so you can provide patients with the highest quality of service. Through Section 179 of the IRS tax code, the U.S. government provides a way to encourage small business owners to take that financial leap. This much-needed tax relief may be the motivation to buy equipment sooner than later and ultimately help grow your practice. Continue reading…

4. Radiation exposure guidelines nuclear imaging

Advancements in medical imaging technology have revolutionized health care, allowing doctors to more accurately diagnose disease and improve patient outcomes. These advancements include a variety of techniques that create detailed images and demonstrate the functionality of organs and tissue inside the body through the use of radiology or radiopharmaceuticals. The word radiation may stir-up heightened concern, especially if you are having multiple tests performed. Continue reading…

3. Key differences between holter monitors and telemetry

Both Holter monitors and mobile cardiac telemetry (MCT) provide ways to monitor a patient’s electrocardiogram for an extended period of time. Their main purpose is to determine the cause of a transient event by recording a patient’s heart rate and rhythm during normal activity. Although similar, Holter monitors and MCT devices have distinctive differences and meet different needs, which impacts the physician’s choice of monitoring method. In this post, we’ve outlined some of the distinct differences. Continue reading…

2. Common questions about mobile imaging

Many physicians are curious about mobile imaging but have questions about the service and how it actually works. As a leading provider of mobile nuclear imaging, the Digirad team has met with thousands of practices and cardiology providers. Here are the answers to the most common questions we receive. Continue reading…

1. Understanding attenuation correction

Attenuation correction is a mechanism that removes soft tissue artifacts from SPECT images. Attenuation artifacts vary among patients, but the most common corrections are to artifacts associated with breast attenuation in women and diaphragmatic attenuation in men. Ultimately, the goal is to reduce the impact of attenuation in order to provide images that are more uniform and allow for higher reading confidence. Here we explore several methodologies of attenuation correction associated with Myocardial Perfusion Imaging. Continue reading…



Upcoming Nuclear CME credit opportunities from ASNC

Posted on: 12.06.16

ASNC’s educational programming is at the core of the society’s mission to provide optimal nuclear cardiology services. The organization offers a variety of courses including interactive web-based activities for CME and CE credit that are designed to increase learners’ competence in the field of nuclear cardiology. These online activities include Meetings on Demand that present digital recordings of live meetings providing on-demand access to some of ASNC’s most popular courses, Journal CME/CE articles, and Self Assessment Modules (SAMs) that allow you to measure your knowledge in nuclear cardiology, and Webinars.

With the end of the year quickly approaching, here are the activities that will expire in December of 2016 and January 2017:

CME: Applying Appropriate Use Criteria in Clinical Practice: Lessons in Choosing Wisely

This is an online case review roundtable activity that highlights the importance of discussion of appropriate use criteria with referring physicians, reinforces the role of clinical judgment and proposes strategies to reduce the number of rarely appropriate studies. Physicians and technologists will gain a better understanding of the value of myocardial perfusion imaging and the role other imaging modalities have for selected patients. The activity offers .5 CME/CE credits and the expiration date is December 3, 2016.

CME: Enhancing Your Nuclear Cardiology Practice Video Series

These are four individual activities addressing best practices in four nuclear cardiology topics. The format for each activity is audio/video synchronized with slides presenting interactive case studies and case challenge questions and expert vignettes. Physicians and technologists will learn about the most current and best practices in nuclear cardiac imaging. Each individual activity is free to members; non-members pay a fee of $50 each.

  1. Pharmacologic Stress: Who, How and Why. This activity offers 0.5 CME/CE credits and expires on December 22, 2016.
  2. SPECT: The Workhorse of Cardiac Imaging. This activity offers 1.0 CME/CE credits and expires on December 22, 2016.
  3. Appropriate Use Criteria: Application and Benefit. This activity offers 0.5 CME/CE credits and expires on December 22, 2016.
  4. PET: Advancing into Clinical Practice. This activity offers 1.0 CME/CE credits and expires on January 10, 2017.

To view all of the ASNC online educational products at a glance, click here.



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