Maternal-Fetal Medicine Foundation
Nuchal Translucency Quality Review Program
November 10, 2006, Issue No. 1



INSIDE THIS ISSUE


» Introduction
» NTQR Myths and Facts
» Especially for Sonographers
» Counselors Corner
» Coding Connection
» Criteria for NT Measurement
» NTQR Fast Facts

"The NTQR web-based course is outstanding. The content, methodologies, and feedback provided are superb and the information is presented in an organized and interesting manner. I was impressed with the amount and quality of information I was given. For anyone doing NT measurements, the NTQR program is a must."



Patrick S. Ramsey, M.D., M.S.P.H. ACOG JFCAC Chair Director, CRWH Biorepository Associate Professor - OB/GYN & Public Health University of Alabama at Birmingham

Introduction


The Nuchal Translucency Oversight Committee
It is our pleasure to present the first edition of the Nuchal Translucency Quality Review (NTQR) Program Newsletter, the NT Examiner. We intend the newsletter to be a quarterly update of information and activities of the NTQR Program. Our audience is our key stakeholders; providers of NT and first trimester risk assessment as well as laboratories, allied associations and societies, and insurers. The newsletter aims to be informative and perhaps just as importantly, we hope that it will encourage you to let us know what more we can do to expand and enhance the NTQR Program.


About NTQR

Who We Are
The Nuchal Translucency Quality Review Program is a consensus based national NT education and quality review program which is open to ALL providers of NT measurements and first trimester risk assessment. The program was established by recognized leaders in the field of prenatal diagnosis and continues efforts to involve all relevant clinical professional organizations as well as prenatal diagnostic laboratories. The NTQR Program intends to educate providers not only on technical aspects of NT measurements but also to disseminate information on various strategies for optimization of first trimester risk assessment as well as additional risk factors associated with abnormal NT measurements.

Program Goals
  • Educate providers on methods to obtain reproducible NT measurements
  • Provide a method to evaluate and track provider proficiency
  • Provide ongoing NT quality review


How to Become NTQR Credentialed
  • Go to www.NTQR.org
  • Register and select the appropriate program track
  • Take educational course (web-based or land-based)
  • Pass on-line exam
  • Submit images and corresponding data for review by Quality Review (QR) personnel









"NTQR values and respects all methods
of quality assurance."







NTQR Myths and Facts

By Larry Platt, MD
NTOC Member
Prof. Ob-Gyn, Geffen School of Medicine at UCLA,
Director, Center for Fetal Medicine and Women's Ultrasound


Myth
The NTQR was established as a money-making venture for the Society for Maternal Fetal Medicine (SMFM)

Fact
The NTQR was established by the SMFM when it was recognized that there was a need for a recognized consensus based United States Quality monitoring program for Nuchal Transluceny ,an analyte in the first trimester risk assessment . The Maternal Fetal Medicine Foundation (MFMF) was established as an independent non profit 501 c3 to manage the program. Monitoring fees established are to cover the costs associated with the start up and ongoing costs of the program.

No physician on the NTQR receives any remuneration for their activities with the NTQR or MFMF. Each member (physician and non physician members ) has donated hundreds of their discretionary hours to the start up of this program because they believe it is a very important national precedent for medicine. Fees charged will be only be used to cover program costs .There is no plan to generate any profit from this venture.

One must remember that even "free" programs have expenses that must be covered by someone. The committee members are doing everything they can to seek alternate sources of funding including grants. We invite your suggestions .

Myth
NTQR believes that Nasal bone assessment is of no value in first trimester risk assessment.

Fact
Nasal bone is a very valuable marker which is best used as a secondary test.

Myth
NTQR does not accept any registrant who has been credentialed by another organization.

Fact
NTQR values and respects all methods of quality assurance.

Myth
The place to make the measurement of the nuchal translucency for the NTQR is different than where the measurement is made for Fetal Medicine Foundation (FMF).

Fact
The measurements are in the exact same place - on the inner part of line with none of the horizontal cross bars protruding into the free space.

The NTQR Stance on Nasal Bone Assessment
NTQR believes that nasal bone assessment is a valuable additional marker in the assessment of risk for trisomy 21. Nasal bone is a marker that should not be used in isolation but rather as a secondary or contingent test as part of first trimester down syndrome risk assessment. The methods for Nasal bone imaging in the first trimester requires evidence of education and training. The question of ongoing quality assurance has not yet undergone thorough scientific evaluation but in fact may be the method used in the future to maintain competence and consistency of reporting.


Especially for Sonographers
By Jean Lea Spitz, MPH, RDMS
NTOC Member
President SDMS
Prof. and Chairman, College of Allied Health
Univ. of Oklahoma Health Science Center

It takes partnerships to provide quality nuchal translucency services to our patients. The teams typically include an NT credentialed sonographer to provide accurate measurements, a laboratory to correlate the measurement with serum tests, a physician or genetic counselor to educate patients about the procedure and outcome, a facility to provide further testing if required, and an organization to provide education, credentialing, and monitoring of team members. The nuchal translucency measurement is not like other measurements that sonographers perform. It must be accurate within fractions of millimeters. A measurement done to date a pregnancy may be rechecked later in the pregnancy. If the nuchal translucency measurement is done incorrectly between 10 weeks 3 days and 13 weeks 5 days there is not another chance. Decisions that may impact a family for a lifetime are based on this measurement. The Code of Ethics for the Profession of Diagnostic Medical Sonography "promotes excellence in patient care by fostering responsibility and accountability among diagnostic medical sonographers." For provision of nuchal translucency services this means to me that the sonographer will:

  • Demonstrate competency in obtaining nuchal translucency measures by completing the education and certification process offered.
  • Obtain appropriate sonography education, certification, and clinical skills to insure competence in meeting additional examination requirements for obstetrical patients.
  • Work in collaborative partnership with a supervising physician available to counsel with patients about the nuchal translucency measurement.
  • Be accountable for accuracy and participate in regular monitoring and review of protocols, procedures, equipment and results.
  • Respect the roles and strengths of partnership. Promote the best in every member of the team.
  • Apply ALARA principles during sonography examinations.
  • Place patient care as the highest priority.

Specific technical requirements for the nuchal translucency measurement are available through the NTQR and other web sites. For sonographers, learning to perform the measure consistently and accurately and becoming credentialed is the first step. But just doing the measurement is not enough. Sonographers need to do their part to insure that continued monitoring is in place and that a full partnership is available to provide optimum patient care for the obstetrical patients they see.


Counselor's Corner
By Renee Laux, MS
NTOC Member
NSGC Representative


With the advent of new options for first trimester screening, genetic counselors face even more challenges in educating patients about their many choices. Counselors will need to discuss the many options for screening available to the patient and be able to explain the differences in simple terms that patients can understand. Below are several important points to be discussed in a counseling session:

  1. As with maternal serum screening and the genetic ultrasound in the second trimester, counselors need to make sure that patients understand that first trimester screening is NOT diagnostic testing and that it does not provide an answer but rather a risk assessment (screening test). If the patient desires an answer as to whether or not their fetus has a chromosome abnormality, they should consider CVS or amniocentesis (diagnostic test).
  2. Counselors also need to discuss that first trimester screening does not screen for all chromosome abnormalities nor does it screen for open neural tube defects and if this is also desired what strategies will be employed for this additional screening.
  3. Counselors need to convey to patients that if a patient chooses to have first trimester screening, that the results could comfort them if their risk decreases but also that the results could increase their risk which could lead to increased anxiety and to the choices for further testing. If a patient clearly states that they would not have diagnostic testing, then they need to seriously consider how screening could help them. If they choose to have first trimester screening, they need to have the option of CVS available to them. If this option is not available nearby, then they need to be informed of this prior to first trimester screening. If they would choose not to have CVS, then they may have several anxious weeks to wait to have amniocentesis.
  4. Lastly, counselors need to discuss the possibility that a nuchal translucency measurement may not able to be obtained and at that point they may need to reconsider their options for other screening strategies.







Further discussion about counseling issues will be in future newsletters including combined, fully integrated, serum integrated, sequential and contingency screening strategies.



Coding Connection

By Dan O'Keeffe, MD
NTOC Member
Medical Director Phoenix Perinatal Associates. Phoenix Arizona

Members of the Nuchal translucency Quality Review Committee, along with the Society for Maternal-Fetal Medicine's Coding Committee, worked for three years to obtain a CPT code for nuchal translucency. Starting January 1, 2007 there are two new CPT codes. 76813 is the CPT code for ultrasound examination for nuchal translucency measurement of the first fetus. 76814 will be the CPT code for ultrasound examination for NT measurment for each fetus after that. These CPT codes can be billed along with a 76801 (first trimester ultrasound) when done for an appropriate indication. Until January 1, 2007, there is a white paper on the Society for Maternal Fetal Medicine's web site, under the coding section, that gives a detailed description of how to bill for nuchal translucency.

Summary of the White Paper on Nuchal Translucency Billing.

A nuchal translucency ultrasound consists of nuchal translucency measurement, a fetal crown rump length measurement and assessment of fetal viability. These are not the components of a 76801 (first trimester ultrasound), therefore a 76801 should not be billed unless you have received permission, in writing, from the health plan to use the 76801 in this manner. In discussions with most major insurance companies in a number of markets it appears that the 76999 code (unlisted ultrasound procedure) is a CPT code that they recommend to be used. This unfortunately will generate additional work because you will have to send in paper claims that go through medical review. If you do not send in the paper claims, there will be denials and delays so you might as well do that upfront.

It would also be wise to contact your local payers and make sure they are in agreement with this and if this is in their billing system. If the referring physician requests a first trimester ultrasound in addition to a nuchal translucency, proper billing would be 76801 and then 76999 with a 59 modifier.

Again this will only need to occur until January 1, 2007 when the new CPT codes come into effect.




Criteria for Nuchal Translucency (NT) Measurement
By Steven L. Warsof, MD
Prof. Ob-Gyn, Eastern Virginia Medical School
Director, Center for Advanced Fetal Therapy

1. Fetal CRL between 38-84mm
2. Margins of NT edges are clear
a. Clear image
b. Angle of insonation is perpendicular to
NT space
c. Clear NT lines
3. Fetus in Mid Sagittal plane
a. Midsagital view of fetal spine seen in
cervical & thoracic region
b. Tip of nose seen in fetal profile
c. Third & fourth ventricle seen in CNS
d. Should not see ribs, stomach or heart
4. Fetus occupies majority of image
a. Image predominately filled by fetal head
neck and thorax
b. The fetus should occupy >50% of image
5. Fetal head in neutral position
a. Amniotic fluid seen between chin and chest
b. Angle <90 degrees
6. Fetus observed away from amnion
7. Measurements
a. Use the + calipers
b. Place crosshairs on the inner edge, but not
in the clear space
c. Measurement is perpendicular to long axis
of the fetus
d. Measure at widest space
e. Use largest of 3 technically correct
measurements


      NTQR Program Fast Facts



Program Statistics
  • Over 1,900 providers of NT measurements have registered with the Nuchal Translucency Quality Review Program
  • 1,250 providers have been credentialed through NTQR
  • Over 3,600 NT images have been reviewed by NTQR's Expert Reviewers
  • Twelve laboratories currently participate with the NTQR Program, to view the list of our partner laboratories, go to www.NTQR.org


Upcoming Land-based NTQR Courses
  • November 10-11, 2006: 9th Annual Mid-Atlantic Ultrasound Symposium for Obstetrics and Gynecology and Nuchal Translucency at the Ramada Plaza Resort - Virginia Beach, VA Registration Information (757) 446-6140
  • November 30 - December 3, 2006: 15th Annual OB/GYN Ultrasound Update for Clinical Practice at the Lago Mar Resort & Club - Fort Lauderdale, FL Registration Information (310) 821-8441
  • January 28-30, 2007: OB-GYN Ultrasound 2007 at the Westin Riverwalk - San Antonio, TX Registration Information (888) 207-9105
  • February 10, 2007: 27th Annual Meeting The Pregnancy Meeting at the San Francisco Hilton & Towers - San Francisco, CA Registration Information (202) 863-2435
  • March 15-18, 2007: 2007 AIUM Annual Convention at the Marriott Marquis Hotel - New York City, NY Registration Information (800) 638-5352
Top Tip:
You know you are NTQR credentialed but can't remember your credentialing number. What do you do?
A link to your NTQR credentialing certificate is available on the "Provider Summary" page. Simply log on to www.NTQR.org and the first page that appears is your provider profile. Click on Print Certificate of Completion. The credentialing number, a.k.a. NTQR Provider ID, appears on the certificate.

EDITOR-IN-CHIEF
Steven L. Warsof, MD
warsofsl@evms.edu


LETTERS AND OTHER INQUIRIES
Send letters to the editor and all other inquiries to the NT Examiner newsletter,
Nuchal Translucency Quality Review 409 12th Street, SW
Washington, DC 20024, or send e-mail to NTQRSupport@ntqr.org.