Whitney Palmer

Incomplete Documentation Shrinks Your Bottom Line

Published on the July 24, 2012, DiagnosticImaging.com website

By Whitney L.J. Howell

In the wake of the latest proposed radiology reimbursement cuts from CMS, documentation is more important than ever. And experts say your poor documentation may be to blame for your leaving rightfully-earned money unclaimed.

In fact, it’s common for radiologists to forego as much as 10 percent of overall legitimate revenue, according to Richard Duszak, MD, FACR, a radiologist with Mid-South Imaging and Therapeutics in Memphis and regular coding and billing columnist for the Journal of the American College of Radiology. While coders are your partners, they can only file for reimbursement based on the information you provide. It’s your responsibility, he said, to be vigilant.

“Each report must answer three questions: why, what, and how,” he said. “Not the clinical questions, but why did you do the exam, what is the clinical history of the body part imaged, and how was it imaged. Did you use plain films, was contrast present, how many views?”

Problem Areas to Watch

Incomplete documentation in three areas account for approximately 75 percent of unclaimed reimbursement, Duszak said. By addressing documentation problems with clinical history, the use of contrast, and ultrasound, you will likely see your revenue grow.

First, work with your hospital partners to examine how information is documented in the emergency room. Often, referring physicians relay information verbally, and it isn’t recorded in the patient record. Without a properly recorded clinical history, coders must code for the lowest level of reimbursement, and radiologists won’t receive proper payment.

Second, pay close attention to documenting when you use intravenous contrast agents with a CT or MRI study. Failing to notate when you do use contrast reduces both technical and the professional reimbursement.

“Simply failing to mention the introduction of contrast in a CT scan will lead to a loss of legitimate revenue – often as much as 20 percent,” Duszak said. “That adds up over time. Radiologists, as a rule, do a lot of these, so it becomes very significant.”

Third, when performing a complete abdominal ultrasound, be sure to document the eight components required for full reimbursement — the liver, gallbladder, bile ducts, pancreas, spleen, kidneys, abdominal aorta, and inferior vena cava. Missing one immediately downgrades the procedure to an incomplete ultrasound, and, based on the 2011 Medicare Physician Fee Schedule, your reimbursement drops by up to $25.

There are other areas where you could potentially be losing money, said Stacie Buck, president and senior consultant at Rad Rx, a coding consulting company that specializes in diagnostic and interventional radiology services. Fortunately, she said, the fixes are easy.

Always document the number and types of views in the body of the report to avoid having a claim down-coded. And, when documenting 3D reformatted images, note the medical necessity for obtaining them as 3D reformatting isn’t standard for MRI or CT exams.

The Coder’s Perspective

In most cases, Buck said, coders know radiologists are performing services that don’t appear in the documentation, but without written evidence, they can’t help you claim the revenue.

“It is very frustrating to coders when they receive conflicting documentation or incomplete documentation,” she said. “It forces coders to down-code encounters, which, of course, costs a practice or facility money.”

Although it can cause a delay in reimbursement, coders also have the option to come back to you for additional information, said Shirley Breslin, client education and coding training manager for AdvantEdge Healthcare Services, a leading radiology billing company. The length of the delay, however, is up to you.

“Delays in payment depend on how willing a physician is to help us. Having to go back to the radiologist can slow down payment anywhere from three days to a couple of weeks,” she said. “Some radiologists are very conscious of the fact that it’s important to get documentation done and done right. But it really comes down to how well the doctor receives hearing that additional information is necessary.”

To read the remainder of the story at its original location: http://www.diagnosticimaging.com/practice-management/content/article/113619/2092203

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