Supervision of Support Personnel in the Use of Modalities

While my interview and the knowledge I got out of it were based on the clinic’s practice of using ultrasound as one electrotherapeutic modality, I did keep in the back of my mind the findings in the above-cited study and wondered what specifically it would mean for my daily practice in the future. From my interview, a lot of clarifications arose regarding frequency of use of the identified modality and the daily logistical, legal and ethical considerations in the practice of the clinic.
The interview highlighted the surprising fact that ultrasound was a modality whose use was only minimal at the clinic and then only to break up fibrotic tissue in an attempt to reduce swelling and chronic pain. The dosage used for chronic swelling was pulse ultrasound at 20% duty cycle while for chronic pain continuous ultrasound at 1.5 MHz for 5 minutes was administered. With regard to the expected therapeutic outcomes and the criteria affecting discontinuation of treatment, the interview identified reduction in both pain and swelling as obvious therapeutic outcomes as measured by a pain scale and reduction of diameter (girth) of swelling. Treatment was discontinued after 8-10 visits because research showed that by the end of that time period, the maximum benefit from electrical stimulation would have been reached.
The reason ultrasound (CPT code 97035) was used for pain control and soft-tissue shortening was because of the therapeutic benefits of localized heat (between 1-4C tissue temperature elevation) as regards increased metabolism, decreased muscle spasms and increased blood flow to the localized site (and thus enhanced healing opportunities). I was also aware that there were non-thermal effects such as stable cavitation, auto streaming and microstreaming and the use of US in special situations where very low doses (0.15W/cm sq intensity at 20%duty cycle) were beneficial to the healing of bone fractures. However, my interview focused on the use of US for mainly soft tissue repair at the clinic, the parameters used, billing and reimbursement procedures, legal and supervisory requirements for setting up a session and the legal limitations placed on differing categories of health professionals.
For example, in my interview with the physiotherapist in the clinic, it became clear that supervisory guidelines prohibited technicians from turning on the ultrasound machine although they could set up the patient by applying ice or heat as appropriate (CPT 97010). This was covered in state law under section 500 of the "Covered services, limitations, and exclusions for occupational/physical therapy services" (Department of Health and Human Resources, rev. 2005) which specified that medical services were to be carried out in line with Title XIX of the Social Security Act and Chapter 9 of the West Virginia Code. In fact section 550 (2005:4) of the West Virgi