Incomplete physician documentation in abdominal ultrasound may occur in as many as one in five cases, and these omissions collectively result in losses to legitimate professional income, according to a study published in the June issue of the Journal of the American College of Radiology.
The findings suggest that use of structured reporting systems may improve documentation and reduce revenue lost to undercoding, according to authors Richard Duszak, Jr., MD, of The University of Tennessee Health Science Center in Memphis, and colleagues.
“Although the primary role of a radiology report is clinical communication, it also facilitates physician risk management and practice revenue management. With downward pressures on physician remuneration, that latter role becomes increasingly important,” wrote the authors.
Duszak and colleagues sought to assess the frequency and financial impact of physician documentation deficiencies through an expansive analysis of a multi-institutional coding and billing database of radiology reports from 37 practices. Language processing software searched nearly 12.7 million reports, identifying 336,062 abdominal ultrasound reports from more than 1,000 radiologists. Exams were categorized as complete or limited based on standard CPT criteria, and the incomplete exams were further sub-categorized based on how many of the eight required documentation elements (e.g. organs such as liver or gallbladder) were included.
Results showed that 75.1 percent of abdominal ultrasound reports documented all eight elements required for a complete exam. Among limited exams, 7.7 percent documented seven elements, 5.6 percent documented six elements, 4.8 percent documented five elements and 13.5 percent documented four or fewer elements.
While a complete abdominal ultrasound exam requires description of all eight elements, individual organs may not be visualized for various reasons, according to the authors. They offered the example of a gallbladder, one of the eight required reporting elements, being surgically absent. In such cases, the radiologist can not document the element.
Since these exceptions exist, they created a documentation deficiency likelihood model, wherein the more required elements were documented, the higher the chance of the exam being intentionally limited. For exams that were “very likely” complete, deficiencies were present in 9.3 percent, but on the other end of the spectrum, exams classified as “possibly complete,” deficiencies were present in 20.2 percent of cases.
The resulting lost professional income amounted to 2.5 to 5.5 percent of legitimate professional payments, according to Duszak et al.
“Although our analysis focused only on abdominal sonography, it is likely that similar documentation deficiencies resulting in undercoding occur commonly in reports of other imaging modalities (eg, radiography, CT, MRI),” they wrote. “These each represent opportunities for ongoing individual physician and practice documentation improvement initiatives, as well as further scholarly pursuits.”
The authors noted that higher ultrasound volume physicians generated more thorough reports, probably due to the fact that physicians who frequently interpreted that particular exam are more likely to be familiar with corresponding practice guidelines, coding rules and routines for thorough reporting.
Duszak and colleagues suggested that tools for structured reporting, such as reporting templates and macros, would be useful in improving documentation, but that would only be one piece of the puzzle.
“Radiology residency programs have placed relatively little emphasis on reporting, and such tools will succeed only if there is sufficient physician educational ‘buy-in,’” they wrote. “A lack of emphasis on reporting training in surgical residency programs has been associated with inadequate, and therefore costly, operative reports, and we believe the same holds true when radiologists receive insufficient training in the importance of thorough documentation.”