Original articleAutomatically Inserted Technical Details Improve Radiology Report Accuracy
Introduction
Since 1996, the US Department of Health and Human Services (HHS) and its Office of Inspector General (OIG) have heightened their investigation of hospital and physician billing practices. This elevated vigilance has resulted in increased denials of improper claims and reduced payments to institutions and providers. Even so, in 2001, CMS improperly paid an estimated $12.1 billion in claims. The Department of Health and Human Services and OIG have put physicians on alert: it is necessary to fully and accurately document services and initiate compliance plans to reduce coding and billing errors. Failing to file accurate claims may result in investigation by both federal and state enforcement agencies [1].
The evolution of medicine requires physicians to adopt new skills. Now more than ever, the modern practice landscape requires physicians not only to master the art and science of medicine but to firmly understand the reimbursement and compliance issues surrounding the delivery of care [2]. The benefits of a compliance program include reducing fraud and abuse, enhancing health care providers' operations, improving health care services, and reducing overall health care costs by preventing the submission of false or inaccurate claims or cost information to federal and state health care programs [3]. The OIG recommends that every institution adopt and implement compliance programs that adhere to applicable federal and state laws and the program requirements of federal, state, and private health plans [4]. The OIG views compliance programs as core aspects of a health care system [5].
In radiology, formal reports are at the core of practice. These documents serve not only the primary purpose of clinical communication but are also the documents on which coding and billing are based. If a service is ever audited for regulatory compliance, the formal report will be the single strongest determining factor. If a service is not documented, it is difficult to prove that it occurred [6]. It is as important that the formal radiology report accurately describe the imaging findings as that it accurately document the procedure performed [7].
Historically, the guidelines for what constitutes a complete radiology report have not been uniform [8]. The structure and content of reports has varied depending on any number of factors, including the intended audience, case complexity, and the experience of the authors [9]. However, at the 2007 Intersociety Conference, participants recommended the use of structured reports. In addition to uniform communication, structured reports facilitate the extraction of key information necessary to document quality metrics linked to financial incentives requested by the Medicare program [7]. The development of an effective and automatic structured report templating system based on procedure codes has the potential to eliminate human oversights in providing the correct header for a report. Such an improvement yields positive effects in both clinical and billing accuracy.
The objective of this study was to evaluate the effect of the automatic insertion of technical details on the discordance between a reported performed radiologic study and the actual performed study. Before 2007, our institution's radiology department manually inserted procedure headers into reports for descriptive and billing purposes. Our dictation system is RadWhere, (Commissure, Inc, New York, New York). This software allows a procedure description to be automatically inserted into a report on the basis of accession coding. Individual staff radiologist report concordance data were compiled over a 4-year period, with approximately half of the data from before and half from after the hospital-wide use of the RadWhere reporting system. We evaluated the concordance of the reports before and after the inception of the automated report system. To our knowledge, this investigation is the first to evaluate the relationship between automated radiology reports and compliance.
Section snippets
Methods
This study was approved by the institutional review board. The requirement for informed consent was waived. Data were reviewed from the radiology billing compliance office between January 2005 and December 2009. The office reviewed random radiology reports on a quarterly basis. A total of 20 quarters were included. The migration from manual to electronic insertion of procedure details took place during the second quarter of 2007. This quarter was excluded from the analysis.
Before the switch,
Results
This investigation included 9,110 radiology examinations that were audited by the hospital compliance office. The numbers for the pre-AITD and post-AITD eras and the second quarter of 2007 were 3,948, 4,598, and 564, respectively. We excluded the examinations from the second quarter of 2007, when the switch occurred.
The percentage of discordance in the pre-AITD era was 3.95% (156 of 3,948; range per quarter, 1.5%-6.1%). According to the discordance of the pre-AITD period, it was expected that
Discussion
Given the rapid changes both inside and outside American medicine, as well as rising health care spending in the United States, a major focus of HHS is the heightened investigation of hospitals to detect fraudulent activity. This effort has reportedly resulted in increased denials of improper claims and reduced payments to providers [1].
The mission of OIG, as mandated by Public Law 95-452 (as amended), is to protect the integrity of HHS programs, as well as the health and welfare of the
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