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Ph. 800-TEX-ACEP
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  September 2012

From the President

Dan Peckenpaugh, MD, FACEP

dan_peckenpaugh_color_picThank you for joining us for another edition of the EMPhasis, updating Texas emergency physicians on the recent happenings in TCEP.

The TCEP Councilors (elected by you) and Alternate Councilors will be meeting in September to plan for the ACEP Council meeting which will be held just prior to the Scientific Assembly in Denver. Our purpose is to review various ACEP resolutions (which govern our College) that will be presented at the Council meeting, and determine whether Texas should support the resolutions. Additionally, we review the candidates for the ACEP Board of Directors and Council Speaker to determine whom we believe will be the best representative for the College for the coming year.

The TCEP Residency and Medical School visit program is in full swing under the guidance of Drs. Angela Fisher, Carrie deMoor and Heidi Knowles. This program has shown significant success in achieving our goals of increasing TCEP’s exposure to our future colleagues, aiding in our membership growth and helping us to develop physician leadership in TCEP. These educational forums continue to generate enthusiasm and positive feedback from the programs we visit. We have been blessed with having the above-mentioned great organizers of this program as well as with the willingness of the various Residency and Medical School program directors for allowing us the opportunity to showcase TCEP to their residents and students.

And speaking of membership growth, we are poised to pass the 1700 member milestone during this calendar year. This increase would allow TCEP to add yet another Councilor to our representation at the ACEP Council, increasing our influence even further. I continue to ask the current members to encourage their colleagues to join us as a member of the most rapid growing and most innovative chapter in ACEP. Our strength, both at ACEP and in Texas, is in our numbers, our member participation and our unified voice.

Additionally, we continue to monitor statewide legislative and regulatory activity for issues that impact the practice of emergency medicine, not only in the clinical arena but the business side of emergency medicine as well. We are working hard at improving our affiliations and building coalitions with our potential allies at both the state and national level, and both inside and outside emergency medicine. Several TCEP members with particular interest in specific areas of EM have helped us to identify some looming issues affecting our specialty, which allowed us to react in a timely fashion to the threats. If you become aware of any issues that have the potential to impact our practices, please notify us.

For those planning to attend the Scientific Assembly, we will see you in Denver. If you have not registered for this event, take this opportunity to sign up for the best educational and networking forum available for emergency physicians.

We will continue to keep you informed on the status of issues important to TCEP. You may contact our chapter office at 800-839-2237 for any question or you may contact me at danpeck@tx.rr.com.

As always, thank you for your continued support.

In This Issue:
News From the Executive Director
Government Relations Committee Report
Ultrasound Programs for Emergency Medicine - Rules of the Road
TCEP Membership Committee Update
Welcome New TCEP Members
News from the Medical Student Committee
BCM Emergency Medicine News

News From the Executive Director

September 1992-September 2012 – TWENTY YEARS!

James E. Coles, CAE, TCEP Executive Director (pictured bottom right)

I would like to thank all the members of the Texas College of Emergency Physicians for the chance to serve as TCEP Executive Director for the past twenty years.  It has been an incredible opportunity with interesting challenges and working with Texas emergency physicians has been the highlight of my career. There are way too many individuals to mention that have impressed me and mentored me with their leadership.   I have seen membership grow from 540 to over 1700 members, coordinated an office relocation from Las Colinas to Austin in 1993, purchased an office for the TCEP Headquarters and was  selected as an ACEP Honorary Member in Boston in 2009. I look forward to serving TCEP for many more years.

TCEP 2012-2013 Board of Directors  >>>View their information here>>>

Dan Peckenpaugh, MD, FACEP

Rick Robinson, MD, FACEP

Bruce Moskow, MD, FACEP

Angela Siler Fisher, MD, FACEP

Nick Zenarosa, MD, FACEP

Shannon Bagwell, MD, FACEP
Carrie de Moor, MD
Juan Fitz, MD, FACEP
Shkelzen Hoxhaj, MD, FACEP
Heidi Knowles, MD, FACEP
Heather Owen, MD, FACEP
Patty Short, MD, FACEP
Harbir Singh, MD
Tim Taylor, MD, FACEP

Jim Coles, CAE
Executive Director

Nancy Davis
Executive Assistant
2525 Wallingwood Bldg 13A
Austin, Texas 78746
FAX: 512/329-8943

PO BOX 619911
Dallas, TX 75261-9911
OFFICE: 800/798-1822
FAX: 972/580-2816

Government Relations Committee Report

Diana Fite, MD, FACEP
Chair, Government Relations Committee

Thanks to all who made the effort to vote in the July 31 primary runoff election.  As a result of the runoff elections, we will likely have two more physicians in the Texas Legislature, although they still have to win the election in November to be official!  Dr. Greg Bonnen is a neurosurgeon in the Beaumont area and won the primary runoff for the Texas House.  And Dr. Donna Campbell practices emergency medicine in the area around New Braunfels and won the primary runoff for the Texas Senate. 

At this point, that makes at least 40 out of 150 members who will be new to the Texas House, and at least 5 of the 31 members of the Texas Senate who will be new.  That creates a tremendous challenge to our lobbyist, Mignon McGarry, and all of us to educate these new members about emergency medicine and medicine issues in general.  We are so grateful to the physicians who are willing to become legislators, which helps us out immeasurably. 

Although many physicians supported Governor Perry in his run for president and Lieutenant Governor Dewhurst in his run for the U.S. Senate, we appreciate that they will still be with us in Texas because they both have promised us continued support to uphold our tort laws.  They were both instrumental in passing our tort reform in 2003.

The TCEP board will finalize during the board meeting September 20 what our legislative priorities will be for the 2013 legislative session.  However, sometimes bills are filed that affect us significantly and our lobbyist has to alert us and change our strategies during the session. The legislative session will be January 8, 2013, through May 27, 2013.  As mentioned in our last report, please remember to set aside the date February 5 to be in Austin for the first of the "First Tuesdays", especially if you will have a new house member or senator.  The TMA sponsors the First Tuesdays, and they will also be held March 5, April 2, and May 7; but we plan to have a strong showing of emergency physicians on February 5. 

As we always remind our TCEP members, we would appreciate you working one shift per year to give to EMPACT (the political action committee for the Texas College of Emergency Physicians).  And larger donations are appreciated, of course.  We need to fund EMPACT so that we can give donations to legislators, particularly those in positions of importance to our issues or who have helped us out with our bills or with support of our agenda.  Our reports emphasize the importance of having a strong voice when it comes to legislation that affects us so directly.  We have to help legislators get elected who understand our issues and help us advocate for our patients.  EMPACT needs money to accomplish this. Please send your check to TCEP or call 1-800-TEX-ACEP with your credit card information.  You can donate with credit card deductions monthly or quarterly if that is helpful.  And you have to renew your donation on a yearly basis. 

Please call me (713-301-3564) or e-mail me (dianafite@mail.com) or call our executive director, Jim Coles (1-800-TEX-ACEP) or e-mail him (texacep@gmail.com), if you wish to discuss any of the information in this report.


Ultrasound Programs for Emergency Medicine - Rules of the Road

Rob Dickson, MD, FACEP

This is going to be a short summary of the benefits of an Emergency Ultrasound program and some resources available to get your group started. In 2001 ACEP approved the first specialty specific guidelines to use of ultrasound in Emergency Medicine. Please refer to the link below to a complete reference for your reading enjoyment. This summary will review the main points regarding ultrasound program development and the business aspects of how to bill for these services. These additional services will additional RVU's to your patient encounter from (.83- 1.6) depending on the study performed.  For a moderate sized ED of volume 55,000 here is an example of revenue left on the table if you do not have an EM ultrasound program. For this example we will use a conversion factor of $33.11 per RVU billed.  (55,000 (volume) * .05 (% exams of total volume)* 1.2 (average RVU) * 33.11 (CF)= $109,263 for the professional component.

Emergency Ultrasound scope of practice and pathways for training

  • EM ultrasound is a focused-goal directed examination that answers specific clinical questions
  • Reimbursed as a separate billable procedure from the E&M code
  • All new residents from ACGME approved Emergency Medicine residencies should be adequately trained in EM ultrasound
  • Practice based pathways- consist of a 16-24 hour introductory course along with at least 25 documented and reviewed cases for each core ultrasound application (FAST, Aorta, Pregnancy Evaluation, etc..) If there is not an ultrasound director (great job for that new EM graduate!!) a log can be maintained by each physician comparing the study findings to other radiologic tests, surgical findings or patient outcomes to assess competency.
  • 10 hours of ultrasound CME on a bi-annual basis for ultrasound directors and 5 hours for individual credentialed physicians
  • Credentialing issues with hospital staff should be addressed by reviewing section 4 of the ACEP ultrasound guidelines for credentialing (link below)
  • A quality assurance process to review images for technical quality and interpretations for clinical accuracy must be in place

Core ultrasound applications

  • Pregnancy – detection of IUP, ectopic, detecting free fluid, detecting heart rate, estimate gestational age
  • Abdominal Aortic Aneurysm- detection of AAA
  • Emergent Echocardiography- detect pericardial effusion, cardiac activity, central venous volume status and global assessment of contractility
  • Gallbladder ultrasonography- detection of gallstones, gallbladder wall thickness, pericholecystic fluid, sonographic Murphy’s sign and common bile duct diameter
  • Urinary tract- hydronephrosis and bladder status
  • DVT- multilevel compression testing of proximal leg veins
  • Soft tissue- detecting abscess/fluid collection, foreign body
  • Thoracic- detection of pleural effusion and pneumothorax
  • Ocular- detection of retinal detachment, vitreous hemorrhage, and dislocation of lens
  • Procedural guidance- venous access-peripheral and central, thoracentesis, paracentesis, and joint aspirations

Coding and Reimbursement pearls

  • AMA has a policy supporting reimbursement for ultrasound imaging performed by appropriately trained physicians
  • All studies must have documented medical necessity (usually driven by ICD9 diagnosis codes)
  • In general the documentation requirements are a procedure note detailing indication, performing physician, organ studied and interpretation of findings
  • Ultrasounds performed by EP's may be coded in addition to E&M codes
  • EP's perform limited studies which are covered by a different CPT code than a complete (radiologist standard) study
  • CPT modifiers are added when the procedure described by the CPT code is altered from the original CPT description
  • A limited EP study and complete radiologist study may be billed for the same encounter if there is medical necessity for example an inconclusive pregnancy evaluation by the EP followed up by a formal  complete study

Common modifiers

  • CPT codes for limited ED ultrasound are a global code with facility charge and professional charge built in. If you are a hospital based EP and the machine is hospital property you must add the professional component modifier- an exception would be a free standing private ED or clinic

Note: if you charge a global CPT for emergency ultrasound you must have a system to archive the images, in a professional charge CPT modifier there is no such requirement

  • (-26) Describes the professional component (doc charge) to complete the exam and interpret/record the results
  • (-52) Describes when the service is partially reduced or eliminated at the physician discretion
  • (-76) Describes a repeat examination by the same physician- an example may be a repeat FAST exam due to clinical deterioration
  • (-77) Describes a repeat examination by another physician (one in a different specialty or group) an example would be if the trauma patient were signed over to the trauma surgeon who repeated the exam
  • Examples of commonly billed ED codes
  • FAST exam- billed under partial abdomen 93308-26 and partial cardiac 76705-26 (1.6 total RVU's)
  • Limited pregnancy evaluation 76815-26 (0.92 RVU's)
  • Limited Aorta 76775-26 (.83 RVU's)
  • Right upper quadrant gallbladder limited 76705-26 (.84 RVU's)

2008 ACEP Ultrasound Guidelines

ACEP Emergency Ultrasound Coding and Reimbursement

Correspondence to:
Rob Dickson, MD, FACEP
Leading Edge Medical Associates
700 East Marshall ave.
Longview, TX 75601


TCEP Membership Committee Update

Sara Andrabi, MS IV, Baylor College of Medicine Medical Student Leadership Initiative Director & At-Large Member TCEP Medical Student Committee

Ashley Bailey-Classen, MS II, Texas College of Osteopathic Medicine At-Large Member TCEP Medical Student Committee

Angela Siler Fisher, M.D., Associate Chief for Operations & Public Affairs, Baylor College of Medicine; Medical Director Ben Taub General Hospital Emergency Department

TCEP has experienced unprecedented growth and participation, now surpassing the 1700 membership mark with greater than 1100 active members coupled with candidate resident and medical student members. As the third largest state chapter, we are excited to increase our representation of Texas Emergency Physicians in the American College of Emergency Physicians council with the expansion to 17 counselors.

Our EM Futures program is the main reason for our marked membership growth. This nationally recognized innovative program focuses on recruiting and engaging members across the EM career spectrum. This has helped fulfill goals such as increasing the visibility and publicity of emergency medicine as a specialty, opportunities for networking, leadership development, and mentorship all the while increasing membership participation. The implementation and continued commitment to the EM Futures program is critical to membership growth.

The mentorship program is the backbone of the EM Futures program. This program provides for opportunities to gain advice, shadowing, networking opportunities and mentorship for medical students, residents, and young physicians who are members of TCEP. Although there are proper channels for setting up elective rotations, having a mentor advocate in a program of interest ensures additional support and resources. The database is organized by region according to the Texas Emergency Medicine Task Force regions and simultaneously serves as a source of speakers for TCEP Residency Visits and Medical Student Leadership Initiative meetings. It will formalize TCEP’s strong history of nurturing its members to their full potentials and creating a culture of leadership and advocacy development.

It's Time to Update Our Mentor Database

If you are considering being a mentor, know someone who would be interested in becoming a mentor or are currently a mentor and have updated information, please visit the following survey: TCEP Mentor Contact Data

To view the current Mentor Database please visit: http://www.texacep.org/displaycommon.cfm?an=1&subarticlenbr=22


Welcome New TCEP Members

Mani Alavi, DO, JD
Abdulla Basnawi, MD
Zachary Baum, DO
Arseny Bezprozvanny
 Toral Bhakta, DO
Melissa Campbell, MD
Myla Canales
 Kelly Dewey, DO
Andrew Dickhute, MD
Kristina Domanski, MD
Thomas Ence
 Stephanie Erzinger
 James Falcon, MD
Alex Harding
 Theresa Harring, MD
Jorge Heredia, MD
Bradley Jacobson, MD
Joshua Keithley, MD
Randi Lindstrom, DO
Hilary McFetridge
 Omar Metwalli
 John Michael
 Casey Mullen, MD
Justin Oring
 Derek Ou, MD
Erin Owens, MD
Jeremy Padalecki, MD
Elizabeth Park, MD
Joshua Parker, MD
Alyse Power
 Manuel Rodriguez-Acosta, MD
Jaron Santelli, MD
Archana Shah
 Kaylin Siever, MD
Farzad Soleimani, MD
Daniel Solomin, DO
Adam Summers
 Jessica Swanson
Doreen Teoh, MD
Mary Tocco, MD
Alainya Tomanec, MD
Mary Werick, MD
Addison Whetstone
 Jason Wright, MD
Shaun York, MD
Christopher Zernial


News From the Medical Student Committee

Michael Pandya, MS III, UT Medical School at Houston At-Large Member
Ben Karfunkle, MS II, UT Medical School at Houston At-Large Member
Melanie Stanzer, MSIV, Secretary-Editor, Medical Student Committee

michael_pandya_profile_pictureWhile many of us had a short break from rotations or classroom education, we continued to work hard on our TCEP projects. We have been busily working to set up Medical Student Leadership Initiative visits at each medical school to introduce medical students to organized emergency medicine. To assure we reach each school, we are asking EMIG leaders to make sure that their organization sends us their preferred dates to Sara Andrabi, MSIII BCM at (Andrabi.sara@gmail.com). Furthermore, we are working on expanding the EMRA Match Away Elective Database and starting to get into gear to set up a great Medical Student Track at the 2013 Annual Meeting!

Starting this month, the Medical Student Committee looks forward to supplementing our own monthly remarks with updates from students at each Texas medical school about how emergency medicine is being advanced and promoted on his or her campus. In this edition, Ben Karfunkle (MS-II) & Michael Pandya (MS-III) share some of the exciting opportunities afforded to members of the Student Society for Emergency Medicine (SSEM) at the University of Texas Medical School at Houston:

In today's advanced health care systems, medical care often beginsben_karfunkle well before our patients reach the doors of the emergency center.  Management of patients in the pre-hospital setting and management of pre-hospital providers require a unique set of skills, to which we, as medical students, are rarely exposed.

Starting this month, students at UT-Houston and Baylor College of Medicine have the opportunity to experience the work of an EMS Medical Director and paramedics firsthand.  Through a partnership with the Houston Fire Department (HFD) and with the help of HFD Assistant Medical Director and Assistant Professor of Emergency Medicine at UT Health, Dr. Keith Gates, students have the opportunity to ride along with paramedics and Dr. Gates as they respond to calls in the fourth largest city in the country. By working with Dr. Gates, this program serves as an excellent opportunity for medical students to discover the American Board of Emergency Medicine's newest subspecialty - Emergency Medical Services.  By working with HFD Paramedics, students will gain an appreciation for the practices and protocols involved in pre-hospital care, a bit of knowledge that will add greatly to the students' relationships with EMS when working in the Emergency Departments.

In addition to our new Ride-Along program, UT-Houston's EMIG continues to offer our students the opportunity for shadowing in the ED, research with the Emergency Medicine Research Associate Program (EMRAP), and certification in BLS and BLS Instruction.

Medical students at UT-Houston will have access to a second new program this year that will place them with first year residents on ultrasound rotation, as well as EM ultrasound fellows. Students interested in emergency medicine and those who just want to get more exposure to the tecmelanie_stanzerhnology will practice reading ultrasounds with every FAST exam, invasive IV placement, and ECHO on their shift, with plenty of time left over to learn from what is happening in the rest of the Memorial Hermann Hospital Emergency Department.

The UT-Houston Student Society of Emergency Medicine and Baylor College of Medicine Emergency Medicine Interest Group would like to thank Dr. Gates, Daryn Donathan, and Jeff Mattingly for organizing this exciting new opportunity for Houston-area medical students with HFD. We would also like to thank UT-Houston's Ultrasound team - Drs. Gregory Press and Sara Miller - for their help with the Ultrasound Shadowing program. If your EMIG would like information on how these programs were devised and put together, please feel free to contact us through our website - https://sites.google.com/site/ssemuth/.


BCM Emergency Medicine News

Join our Section of Emergency Medicine in congratulating our EM Faculty on their recent successes and accolades. 

  • Dr. Frank Peacock co-authored landmark publication in the New England Journal of Medicine (NEJM) on the use of CT Angiogram for Acute Coronary Syndrome Evaluation, ROMICAT.
  • Dr. Gil Shlamovitz was named Assistant Medical Director of Clinical Information Systems for the Harris County Hospital District.
  • Dr. Mark Escott was named EMS Medical Director for the Montgomery County Hospital District. 
  • Dr. Angela Siler Fisher received the 2012 Emergency Medicine Foundation ED Director of the Year Distinguished Recognition Award.
  • Dr. Ira Nemeth was appointed to the American Red Cross Scientific Advisory Council.

2012-2013 Calendar of Events


July 2012
19 JPS Residency Visit Fort Worth, TX
26 UTSW Residency Visit Dallas, TX

August 2012
1 Baylor Residency Visit Houston, TX
2 UT Houston Residency Visit Houston, TX
9 BAMC Residency Visit San Antonio, TX

September 2012
13 Christus Residency Visit Corpus Christi, TX
20-21 TCEP Board of Director's Meeting Houston, TX

October 2012
5-11 ACEP Scientific Assembly Denver, CO
11-12 ACEP Board of Director's Meeting Denver, CO
19-20 TMA Fall Conference ATT Center Austin, TX

November 2012
1 Scott & White Residency Visit Temple, TX
10-13 AMA House of Delegates Interim Meeting Honolulu, HI


January 2013
TBA ACEP Board of Director's Meeting Dallas, TX

February 2013
1-2 TMA Winter Conference Austin, TX
4 TCEP Board of Director's Meeting Austin, TX
5 First Tuesday at the Capitol TMA, Austin, TX

March 2013
5 First Tuesday at the Capitol Austin, TX

April 2013
2 First Tuesday at the Capitol Austin, TX
11-14 TCEP Annual Meeting Frisco, TX
14 TCEP Board of Director's Meeting Frisco, TX

May 2013
7 First Tuesday at the Capitol Austin, TX
15-19 SAEM Atlanta, GA

June 2013
15-19 AMA Annual Conference Chicago, IL


Texas College of Emergency Physicians
2525 Wallingwood Drive, Bldg. 13A | Austin, Texas 78746
Phone: 512.306.0605 | Toll Free: 800.TEX.ACEP | Fax: 512.329.8943

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