Radiologists
Losing Money with Incomplete US Documentation
By
Marijke Vroomen Durning, RN |May 30, 2012, Diagnostic Imaging News
Radiologists may be losing income
through incomplete physician documentation in abdominal ultrasounds, according
to a study published in the June issue of Journal of
the American College of Radiology.
Using a coding and billing database
and natural language processing software, researchers reviewed nearly 12.7
million radiology reports from 37 practices to identify and analyze abdominal
ultrasound reports. A total of 336,062 abdominal ultrasounds were identified.
The exams were categorized as complete or limited, based on standard Current
Procedural Terminology (CPT) criteria. Incomplete exams were sub-categorized
according to which documentation elements were included.
Richard Duszak Jr., MD, of The
University of Tennessee Health Science Center in Memphis, and colleagues found
that 75.1 percent of the reports documented all eight elements for CPT coding
as complete examinations, 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. The researchers found that the spleen was
the most frequent element neglected at 41.2 percent.
Not all organs can be included in
the reports, as in cases of absent organs (gallbladders, for example), so the
researchers took this into account when determining their documentation
deficiency model.
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