Marcus Snow, MD, is a rheumatologist in a multispecialty clinic in Nebraska. During the average day, the nephrologist in his clinic can assess urinary sediment. The urologist can examine semen specimens for viability. However, despite clinical training and competency, Dr. Snow and his rheumatology colleagues cannot perform synovial fluid crystal analysis for their patients.
The Centers for Medicare and Medicaid Services (CMS) requires laboratories conducting synovial fluid crystal analysis and other “moderately complex tests” to be Clinical Laboratory Improvement Amendments (CLIA) certified. Many practices find the process of CLIA certification too burdensome to complete, and often, only the main laboratory in a large healthcare system possesses the certification. Or, rheumatologists must rely on a third-party laboratory.
The ACR & the RFI
The CMS does allow for special exceptions for nine “provider-performed microscopy” procedures, including the evaluation of urinary sediment and qualitative semen analysis. The ACR is currently working through the CMS Request for Information (RFI) process to seek such an exemption for synovial fluid crystal analysis.
“What we’re trying to do with the RFI is ask the CMS to consider synovial fluid crystal analysis on par with nephrologists looking at urinary sediment,” says Dr. Snow, who serves on the ACR’s Committee for Rheumatologic Care (CORC). The issue was raised at a recent CORC meeting when reviewing past position statements.
“For some of the practitioners in the room, it was a non-issue,” says Dr. Snow, at the University of Nebraska Medical Center. “For others, like me, it’s a big issue.”
Synovial fluid crystal analysis was developed by rheumatologists and is a required component of the rheumatology fellowship and continuing medical education. As the ACR’s position statement explains, rheumatology fellowship directors have developed a core curriculum for synovial fluid analysis, and a rheumatologist may not become board certified or remain certified without competency in the technique.
The Benefits of In-Office Analysis
Synovial fluid crystal analysis must be done on fresh samples. At his clinic, Dr. Snow can collect the sample, but then must send it to his medical center’s central lab. Results may not be available for 24 hours. His institution could not take on the cost and bureaucratic burden of achieving CLIA certification in the clinic where he practices.
However, if the CMS allowed rheumatologists to examine and bill for synovial fluid crystal analysis in office, it would save time—a patient could receive a diagnosis immediately—and potentially, money.
“If I see someone for potential gout and I can confirm it’s gout with synovial fluid crystal analysis, I save the system money and additional work-up, because I can cut to the chase and start immediate treatment. The number of additional tests I will perform is likely to be reduced significantly,” Dr. Snow says.