- Email: [email protected]
Documentation Means Dollars: A Few Simple Tips for Better Reimbursement
THE BOTTOM LINE
RICHARD DUSZAK, JR, MD
Documentation Means Dollars: A Few Simple Tips for Better Reimbursement “I’m not getting paid as much as I should. Can you recommend a new billing company?” It’s a question I hear frequently, but usually the person asking it doesn’t like this part of my answer: “Have you audited your dictations?” Billing companies, like anything else, can be good or bad. But they’re only one step in the complex process of getting paid. When radiologists believe they’re not collecting as much as they should, some introspection is usually in order. Not infrequently, the billing company is doing an adequate job—with the reports they get. They can bill only what was coded, and they can code only what was documented. If a radiologist doesn’t sufficiently document what was done, a billing company can’t do its best to collect. Garbage in, garbage out. Good documentation, at least for billing purposes, isn’t hard, but it does take commitment and time (but not that much). Practices that have successfully maximized their legitimate revenue have often engaged in ongoing physician education, spending, for example, a few minutes at group meetings highlighting strategies for improving documentation. Although the list of suggestions that could be offered to radiologists is lengthy, the half dozen tips outlined below are usually considered to offer good bang for the buck and will allow most practices to improve their bottom lines, with very little work or headache. PLEASE TRY THIS AT HOME Clinical History Payment for physician services is predicated on medical necessity [1]. Although the burden for providing
appropriate histories technically falls on treating physicians, radiologists need to include this information in their insurance claims. Unfortunately, when a history is handwritten in a medical record or relayed by telephone from the ordering doctor or to the technologist directly from the patient, it has no way of getting to the billing company. That’s where our reports come in. The solution for communicating such information to your coders and billers is to dictate whatever legitimate clinical information available. Including this information in your report can mean the difference between getting paid and not. Body Part A terse “no fracture or dislocation” is useful to emergency physicians, assuming they know what body part was imaged. But unless we dictate basic anatomic information, getting paid can be difficult. Hospital headers frequently include generic terms such as “extremity,” but Current Procedural Terminology® (CPT ®) coding requires more specific body part information, such as “shoulder” or “hand.” If it’s not in the report, it can’t be coded. And although a computed tomographic study “from the diaphragm to pubic symphisis” is anatomically a study of the abdomen and pelvis, many coders unfortunately consider it only an abdominal study and neglect to bill for the pelvis. This can cut your legitimately deserved reimbursement by almost half. For all studies, state what body part was imaged, and whenever possible, do it in simple terms that coders and auditors will understand.
© 2009 American College of Radiology 0091-2182/09/$36.00 ● DOI 10.1016/j.jacr.2009.05.017
Number of Views Plain-film studies are coded based on the number of views performed [2]. Radiologists need not know all the codes, but they need to dictate the number of views, so their coders can do their jobs. For compliance purposes, coders are instructed to take a de minimus approach to CPT coding, meaning that if they don’t know how many views were performed, they will assume the least. Sometimes, that means leaving money on the table. The only sure way they know what you did is by what you said. For a one-view vs two-view chest study, for example, this translates to an almost 25% difference in collection between radiologists who document thoroughly and those who don’t. Organs Imaged For ultrasound, unlike computed tomography or magnetic resonance imaging (MRI), CPT codes for abdominal, pelvic, and obstetric imaging are based on adherence to very organ-specific documentation criteria. If a laundry list of structures, all based on clinical guidelines, is documented, a higher level code is appropriate. Miss an organ or two, and a lower level code is used. If you’re performing a complete examination, check the documentation requirements [2] and create a report macro to help you meet that burden. The dollar difference between a limited and complete abdominal ultrasound study, for example, is about 35%, so if you perform a full examination, make sure you report one. 613
614 The Bottom Line
Contrast
NAYSAYERS ABOUND
The CPT code families for computed tomography and MRI are structured with noncontrast, contrast, and precontrast and postcontrast codes, of increasing value, but radiologists performing more complex examinations frequently fail to provide adequate documentation. This happens most frequently when precontrast and postcontrast studies are simply reported “with contrast.” For studies such as MRI of the brain, the dollar difference between a noncontrast study and one performed before and after contrast is almost double. The fix is easy: get in the habit, for all computed tomographic and MRI studies, of reporting them “with intravenous contrast” or “before and after intravenous contrast” when appropriate.
Despite compelling financial incentives, some radiologists spend more time complaining about perceived burdensome documentation criteria than just jumping through some simple hoops to get paid. I’ve heard a litany of reasons why radiologists need not bother (all bogus, in my opinion), but here are the two most common:
Resident Supervision Resident salaries are paid, in large part, by government funds. Medicare doesn’t like double dipping, so staff physicians cannot bill for residents’ work unless the attending physicians document their work as well [3]. In short, for diagnostic radiologic services, staff physicians should include language such as “I have personally reviewed this imaging study with the resident and agree with the findings and impression.” For procedural services, attending physicians must document that they were physically present for the entire procedure (or at least its key portions). Many teaching physicians are not getting appropriate payment, not because they fail to properly supervise, but because they fail to document their supervision.
1. It’s in the header. Hospital headers for radiology reports are notoriously unreliable for CPT coding, and many auditors consider them worthless. In far too many circumstances, the header reflects unfortunately neither what was ordered nor what was done but instead what some unit clerk, who can’t tell a femur from a finger, hastily entered into some user-unfriendly computer system. Sometimes, they’re so generic that they’re nonsensical. And unbeknownst to radiologists, the headers are imported from other hospital information systems and sometimes can be changed after a report is signed. What you see is not always what you get! Smart coders ignore these headers and instead rely on radiologists’ reports for correct coding. By documenting appropriately, you make their job—which, by the way, is getting you paid—much easier. 2. It takes too long. Some radiologists lament that they’re too busy doing important work to deal with trivial things such as documenting contrast and numbers of views. Admittedly, I speak pretty quickly, but this rarely adds more than a second or two to my dictation time. If I can
prevent losing $2 for a chest xray (by dictating “two views”) or $40 for a brain MRI study (by dictating “before and after intravenous contrast”) in just a couple seconds, that’s a pretty good use of my time—and probably yours as well. Many of us are not fans of voice recognition software. I’m certainly not. But most systems do allow radiologists to create robust and flexible macros that can make documentation of these seemingly mundane items a snap. Each of these tips is suitable to creating a macro to prompt you to dictate key information (eg, “Blank views of the blank demonstrate . . .”). They’re powerful tools to capture legitimate reimbursement, so use them. THE BOTTOM LINE For radiologists, our reports are important and serve as the most visible products of our work. But they don’t just communicate diagnostic information; they’re also the foundation for our getting paid. How well we get reimbursed for our work depends on a multitude of factors, many outside of our control. Entirely within our control, however, is how well we document what we do. Radiologists who pay attention to reimbursement-specific details stand to get paid better than those who don’t. REFERENCES 1. Duszak R. Diagnosis please . . . if you want to get paid. J Am Coll Radiol 2005;2:447-8. 2. Duszak R. Completely limited coding. J Am Coll Radiol 2006;3:550-3. 3. Duszak R. Teaching physician compliance. J Am Coll Radiol 2007;4:584-5.
Richard Duszak Jr, MD, Mid-South Imaging and Therapeutics, 6305 Humphreys Boulevard, Suite 205, Memphis, TN 38120; e-mail: [email protected].
RICHARD DUSZAK, JR, MD
Documentation Means Dollars: A Few Simple Tips for Better Reimbursement “I’m not getting paid as much as I should. Can you recommend a new billing company?” It’s a question I hear frequently, but usually the person asking it doesn’t like this part of my answer: “Have you audited your dictations?” Billing companies, like anything else, can be good or bad. But they’re only one step in the complex process of getting paid. When radiologists believe they’re not collecting as much as they should, some introspection is usually in order. Not infrequently, the billing company is doing an adequate job—with the reports they get. They can bill only what was coded, and they can code only what was documented. If a radiologist doesn’t sufficiently document what was done, a billing company can’t do its best to collect. Garbage in, garbage out. Good documentation, at least for billing purposes, isn’t hard, but it does take commitment and time (but not that much). Practices that have successfully maximized their legitimate revenue have often engaged in ongoing physician education, spending, for example, a few minutes at group meetings highlighting strategies for improving documentation. Although the list of suggestions that could be offered to radiologists is lengthy, the half dozen tips outlined below are usually considered to offer good bang for the buck and will allow most practices to improve their bottom lines, with very little work or headache. PLEASE TRY THIS AT HOME Clinical History Payment for physician services is predicated on medical necessity [1]. Although the burden for providing
appropriate histories technically falls on treating physicians, radiologists need to include this information in their insurance claims. Unfortunately, when a history is handwritten in a medical record or relayed by telephone from the ordering doctor or to the technologist directly from the patient, it has no way of getting to the billing company. That’s where our reports come in. The solution for communicating such information to your coders and billers is to dictate whatever legitimate clinical information available. Including this information in your report can mean the difference between getting paid and not. Body Part A terse “no fracture or dislocation” is useful to emergency physicians, assuming they know what body part was imaged. But unless we dictate basic anatomic information, getting paid can be difficult. Hospital headers frequently include generic terms such as “extremity,” but Current Procedural Terminology® (CPT ®) coding requires more specific body part information, such as “shoulder” or “hand.” If it’s not in the report, it can’t be coded. And although a computed tomographic study “from the diaphragm to pubic symphisis” is anatomically a study of the abdomen and pelvis, many coders unfortunately consider it only an abdominal study and neglect to bill for the pelvis. This can cut your legitimately deserved reimbursement by almost half. For all studies, state what body part was imaged, and whenever possible, do it in simple terms that coders and auditors will understand.
© 2009 American College of Radiology 0091-2182/09/$36.00 ● DOI 10.1016/j.jacr.2009.05.017
Number of Views Plain-film studies are coded based on the number of views performed [2]. Radiologists need not know all the codes, but they need to dictate the number of views, so their coders can do their jobs. For compliance purposes, coders are instructed to take a de minimus approach to CPT coding, meaning that if they don’t know how many views were performed, they will assume the least. Sometimes, that means leaving money on the table. The only sure way they know what you did is by what you said. For a one-view vs two-view chest study, for example, this translates to an almost 25% difference in collection between radiologists who document thoroughly and those who don’t. Organs Imaged For ultrasound, unlike computed tomography or magnetic resonance imaging (MRI), CPT codes for abdominal, pelvic, and obstetric imaging are based on adherence to very organ-specific documentation criteria. If a laundry list of structures, all based on clinical guidelines, is documented, a higher level code is appropriate. Miss an organ or two, and a lower level code is used. If you’re performing a complete examination, check the documentation requirements [2] and create a report macro to help you meet that burden. The dollar difference between a limited and complete abdominal ultrasound study, for example, is about 35%, so if you perform a full examination, make sure you report one. 613
614 The Bottom Line
Contrast
NAYSAYERS ABOUND
The CPT code families for computed tomography and MRI are structured with noncontrast, contrast, and precontrast and postcontrast codes, of increasing value, but radiologists performing more complex examinations frequently fail to provide adequate documentation. This happens most frequently when precontrast and postcontrast studies are simply reported “with contrast.” For studies such as MRI of the brain, the dollar difference between a noncontrast study and one performed before and after contrast is almost double. The fix is easy: get in the habit, for all computed tomographic and MRI studies, of reporting them “with intravenous contrast” or “before and after intravenous contrast” when appropriate.
Despite compelling financial incentives, some radiologists spend more time complaining about perceived burdensome documentation criteria than just jumping through some simple hoops to get paid. I’ve heard a litany of reasons why radiologists need not bother (all bogus, in my opinion), but here are the two most common:
Resident Supervision Resident salaries are paid, in large part, by government funds. Medicare doesn’t like double dipping, so staff physicians cannot bill for residents’ work unless the attending physicians document their work as well [3]. In short, for diagnostic radiologic services, staff physicians should include language such as “I have personally reviewed this imaging study with the resident and agree with the findings and impression.” For procedural services, attending physicians must document that they were physically present for the entire procedure (or at least its key portions). Many teaching physicians are not getting appropriate payment, not because they fail to properly supervise, but because they fail to document their supervision.
1. It’s in the header. Hospital headers for radiology reports are notoriously unreliable for CPT coding, and many auditors consider them worthless. In far too many circumstances, the header reflects unfortunately neither what was ordered nor what was done but instead what some unit clerk, who can’t tell a femur from a finger, hastily entered into some user-unfriendly computer system. Sometimes, they’re so generic that they’re nonsensical. And unbeknownst to radiologists, the headers are imported from other hospital information systems and sometimes can be changed after a report is signed. What you see is not always what you get! Smart coders ignore these headers and instead rely on radiologists’ reports for correct coding. By documenting appropriately, you make their job—which, by the way, is getting you paid—much easier. 2. It takes too long. Some radiologists lament that they’re too busy doing important work to deal with trivial things such as documenting contrast and numbers of views. Admittedly, I speak pretty quickly, but this rarely adds more than a second or two to my dictation time. If I can
prevent losing $2 for a chest xray (by dictating “two views”) or $40 for a brain MRI study (by dictating “before and after intravenous contrast”) in just a couple seconds, that’s a pretty good use of my time—and probably yours as well. Many of us are not fans of voice recognition software. I’m certainly not. But most systems do allow radiologists to create robust and flexible macros that can make documentation of these seemingly mundane items a snap. Each of these tips is suitable to creating a macro to prompt you to dictate key information (eg, “Blank views of the blank demonstrate . . .”). They’re powerful tools to capture legitimate reimbursement, so use them. THE BOTTOM LINE For radiologists, our reports are important and serve as the most visible products of our work. But they don’t just communicate diagnostic information; they’re also the foundation for our getting paid. How well we get reimbursed for our work depends on a multitude of factors, many outside of our control. Entirely within our control, however, is how well we document what we do. Radiologists who pay attention to reimbursement-specific details stand to get paid better than those who don’t. REFERENCES 1. Duszak R. Diagnosis please . . . if you want to get paid. J Am Coll Radiol 2005;2:447-8. 2. Duszak R. Completely limited coding. J Am Coll Radiol 2006;3:550-3. 3. Duszak R. Teaching physician compliance. J Am Coll Radiol 2007;4:584-5.
Richard Duszak Jr, MD, Mid-South Imaging and Therapeutics, 6305 Humphreys Boulevard, Suite 205, Memphis, TN 38120; e-mail: [email protected].