The correlation between dictation style and reimbursement

Radiologists frequently ask how they can maximize practice revenue. One way is to include proper billing documentation in dictated reports. This strategy will ensure the practice receives proper payment for services and that the proper documentation exists in case Medicare ever conducts an audit.

The radiologist's dictated report is the source documentation to support the services performed, and that report is relied upon extensively in the billing process. Proper coding and billing correlates directly with the quality of information provided by the radiologist. When dictating, close attention to the following areas can have noticeable effects on practice finances.

There are two main audiences for the radiologist's interpretation: the referring doctor and the coders employed by the practice (or the practice's professional billing company). The focus in this article is the information supplied for billing. Medical coders read each report and, based on the information presented in the report, assign a CPT code and a diagnosis code. Coders, just like radiologists, must follow rules promulgated by their professional societies; in this case, the American Health Information Management Association. The best way to ensure proper reimbursement and to remain in compliance with Medicare is to conform to the established norms for documenting radiology examinations. If this information is adhered to, the radiologist will maximize revenue and can be assured that proper documentation exists if he or she is ever audited.

From an exam documentation perspective, there are two separate and distinct types of data in a radiologist's report: data that originate from the RIS, and data that are actually dictated by the radiologist. The dictated portion of the radiologist's report should contain the exact description of what was performed, including the title of the exam(s), the number of views, concentration, and volume of any contrast used.

One of the rules that coders must follow is to code to the lowest number of views (unless documentation exists in the report to report a code representing a greater number of views). The number of views interpreted should always be dictated, even if it is already provided in the portion of the report originating from the RIS. Up to a 38% difference in reimbursement can occur depending on the number of views documented.

Unless special circumstances exist, coders are directed by their professional organization to code for the professional component of radiology exams using only documentation provided by the radiologist, which is the dictated information in the report. The rationale is that over-coding or under-coding can occur if one relies on information derived from the RIS.

For example, the RIS information included in the report title can be different from the exam actually performed. When coding from the radiologist's report, coders frequently find that what the radiologist dictated does not match the name of the exam in the header, which is derived from the RIS of the same report. For this reason, the exact description of the service performed, including the title of the exam, the number of views, and the concentration and volume of any contrast used, should be dictated into the report. By relying on the dictated portion only, one can be sure that the documentation used to assign CPT and diagnosis code(s) reflects the work actually performed.

Here is an example. The header of a report is labeled "Chest Two Views," while the radiologist's dictation is labeled "Chest." Based on coding guidelines, this report should be coded as a one-view chest. Without the radiologist's comments to the contrary, the guidelines say to code to the lowest available number of views. If a two-view chest exam was actually performed, this exam would have been under-coded and under-reimbursed based on lack of information in the report.

Conforming to the established norms for documentation of radiology examinations is also helpful when dictating the results of two different procedures in the same report. When multiple exams are reported in one report, the findings should be separated into distinct, separately labeled paragraphs. Coders read the radiologist's report and determine which services were performed and apply the proper codes. If the findings are combined into one paragraph, the coder may not be able to easily and quickly determine that two procedures were actually performed. As a result, the coder can end up under-coding the report.

If the exams are coded properly and the patient's insurance or Medicare rejects the claim for these services, the billing service must file an appeal. The appeal process includes submission of the radiologist's report. There is a much better chance of a successful appeal if the findings are separated into distinct, separately labeled paragraphs so that the report clearly identifies the different services provided.

The radiologist's report should also contain all information about the indications for the exam at the time that the exam is interpreted. Medicare has developed Local Coverage Decision (LCD) policies for selected radiology procedures. These LCD's contain indications for which Medicare will provide reimbursement for particular exams. If one of the indications included in the LCD is not billed along with the procedure, the charge will be denied. The LCD states, "All services performed for diagnoses not listed as covered in the policy will be denied as not medically necessary." The key to reducing these denials is to provide as much indication information in the radiologist's report as possible.

Documenting the method of imaging guidance used during an examination is crucial as well. Because multiple image guidance techniques are now available, you must document the modality used (CT, ultrasound, or fluorography). The coder may be aware that imaging guidance was used; but unless the modality is documented, that guidance cannot be billed. Also, a permanent recorded image must be produced and stored illustrating that guidance.

The radiologist's dictated report is the source documentation to support services performed. During the billing process, this report is relied upon extensively in order to obtain proper reimbursement. There is no one policy or set of rules that establishes how a radiologist's report should be dictated. The American College of Radiology has developed standards for such communication, but the standards fall short of supporting a specific dictation format. Medicare has documentation requirements but does not provide guidance on dictation format.

When radiologists are disciplined in their dictation style and conform to the established documentation norms discussed here, reimbursement is higher, coders and insurance companies can more easily identify the work performed, there is less likelihood of denials, and proper documentation will exist for Medicare compliance reasons.

Mr. Reinitz is president of Comprehensive Medical Data Management in Powell, OH. He can be reached at kirk_reinitz@cmpminc.com.