The Radiology Report, Refined

It’s often said that radiology’s product is the report. It’s the crucible where referring physicians judge the effectiveness of their subspecialist colleagues, it’s a primary source document for coding and billing, and it’s risk-management documentation in the event of a malpractice suit. In addition, according to Patricia Kroken, FACMPE, FRBMA, CRA, a principal with Healthcare Resource Providers, LLC (Albuquerque, New Mexico), it’s a vital tool for establishing imaging appropriateness. “The radiologist can’t change the order,” she notes, “but if the study was inappropriate, that ought to be documented in the report.” In “Improving Radiology Reports: A Change Management Case Study,” which she presented in Grapevine, Texas, on August 14, 2011, at the annual conference of AHRA: The Association for Medical Imaging Management, Kroken shared the results of a process-improvement project for the radiology report conducted for a hospital-based practice in an urban area. Kroken explains that the project began as part of an overall denials-management program: In looking over coding denials, her team discovered that denials were due largely to a lack of information in reports—and that they were associated with a significant loss of revenue. “This practice has good, ethical coders, and they would not do assumption coding,” she says, “but if it isn’t documented, it didn’t happen.” Straight to the Source As Kroken points out, there is a limit to the amount of responsibility that can be assigned to a practice’s coders; to improve reports, practices must engage their radiologists. This, she warns, can be controversial, and it requires the full commitment of the practice’s leadership. “If you don’t have their support, it will be very difficult to drive this through,” she says. “The meeting where you present this idea will be one hot meeting. It’s very volatile.” When the project began, in 2004, Kroken and her team first established a baseline for comparison: At that time, 4.26% of the practice’s procedures billed were being denied for coding reasons. Once it had been established that physician dictation was a key cause of inaccurate coding or undercoding, Kroken’s team reviewed dictation patterns and compared them with ACR® communication guidelines¹ to establish a set of dictation points that are critical, in terms of billing. These include the exam performed, the number of views, the clinical indication for the study, findings, limitations, and more. “The ACR does you a great favor by outlining all of this, and that’s why we used it,” Kroken says. “What you don’t want to do is go in criticizing reports, because if you’re a nonphysician, they will ask, ‘Where did you go to medical school?’ Anecdotally, the better the medical school is, the worse the report is.” After analyzing how frequently physicians hit the benchmarks established by the ACR communication guidelines, Kroken and her team developed custom workbooks for each physician; the workbooks indicated how their reports stacked up against best practices and gave samples of their problem reports. Blinded samples of ideal reports were also included. “If we don’t show them what we do want,” Kroken notes, “we’re just assuming they will get it. You have to reinforce what you want to see.” Enforcement and Reinforcement Physicians were educated on coding basics, and an administrative employee was assigned to return for redictation any reports that were missing critical elements. Any patterns of incomplete dictation were brought up in monthly board meetings for further enforcement of the new order. “They hated this,” Kroken notes. “It was not a popular program. You’ll see one or two great offenders in a group of 20, and those who are chronic offenders go kicking and screaming through this program. This is absolutely where you need physician leaders reinforcing this for you.” Positive reinforcement, however, was right around the corner. Before long, denial rates improved; in 2007, fewer than 1% of procedures were denied for coding, and in 2009, that number hit 0.41%, demonstrating that the change had been effectively sustained. Practices can still expect to be affected by annual changes in payor rules; “We’ll never get perfect on coding,” Kroken notes. Eliminating denials that originated in reports, however, enabled the practice to focus on other causes of denials, and Kroken says that the practice’s overall culture of quality was enhanced as well. Today, established physicians in the practice provide monitoring and feedback for new physicians. “They now police each other,” she says. “They’ve done a really good job of maintaining the numbers.” For practices that want to implement a similar process-improvement project, Kroken advises that they get the buy-in of physician leaders; that they use an unimpeachable source of best practices, such as the ACR’s communication guidelines; that they provide concrete information in a blinded format; and that they provide continual feedback. “You want to be looking back at the same criteria you did on the front end and be monitoring it and refining it to improve your results,” she concludes. “When you’re doing process improvement, you’re never really done.”