By: Patricia (Pat) Kroken, FACMPE, CRA, FRBMA
I worked as a radiology business consultant for nearly 20 years and at the end of most practice billing reviews, a radiologist would ask “Is there anywhere else we’re leaving a pile of money on the table?”
The answer is “yes.” What’s more, physicians have the power to get that money with minimal effort. Ask any medical coding professional if they ever down-code a procedure due to insufficient information in the radiology report and you will get further affirmation of the missing pile of money.
Following the completion of numerous dictation audits, we observed that approximately 25% of the radiologists in the group were responsible for nearly 75% of the coding issues.
While this wasn’t a formal analysis, over the years it held true enough to indicate missing information is a common problem. It’s also important to note this doesn’t refer to the situation where occasionally even the most conscientious physician missed a dictation element, but that there were likely to be chronic deficiencies among a segment of the group—enough to indicate changing some patterns could pay off financially since each of those omissions represented lost revenue and over the course of a year, a pile of money.
Even more painful for the practice are the radiologists who refuse to participate responsibly for any of a number of reasons. All of the following comments came from real conversations:
- “I’m too busy. Do you know how much time it will take to check my dictation and make sure that extra phrase is there?”
- “This is just an insurance game and has nothing to do with my quality as a doctor.”
- “Why are you asking me to do that now? I’ve been dictating the same way for 30 years and it’s always been good enough.”
Where do the gaps frequently occur?
Complete Abdominal Ultrasound
A complete abdominal ultrasound study requires documentation referencing each of the following: liver, gallbladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta, and IVC. Missing only one element results in the study being coded (and paid) as limited.
What if the few seconds more spent dictating all elements of a complete abdominal ultrasound improved payment by 35%? When considering how many ultrasound procedures are done by a typical radiology practice over the course of a year, the difference could represent a pile of money.
Medical Necessity Denials
Medical necessity denials often occur when there is insufficient information regarding the reason for an imaging study. Absent that information, the denial may also not have an option for successful appeal.
For example, a common medical necessity denial involves a study ordered for an “event” such as a motor vehicle accident or a fall, but with no supporting details to support the indication for the exam. Mentioning the event alone, even if accurate, is likely to result in a denied claim.
The following examples shows how improved documentation can help move this from the “denied for medical necessity” category to a payable one. And further, the necessary information cited was gathered by the technologist when the patient presented for the imaging study.
- The toddler tripped (an event) and fell while he was walking. He struck his head and sustained a contusion. There’s your medical necessity and we’re going to code the contusion. We didn’t code the “trip” or “the fall,” or “struck his head,” we coded the contusion because it establishes medical necessity.
- The farmer was working in his barn and sustained a foot contusion when a horse stepped on his foot. This described an event. Again, there was a contusion and we can code that.
- The last example involves a motor vehicle accident (the event) and there’s pain, swelling and abrasion— swelling and contusion. Look at all of the signs and symptoms provided along with “motor vehicle accident.” As you can see, there are four additional diagnoses we can code.
So many times, all you get is “motor vehicle accident.” When you have only motor vehicle accident as an indication, push back on the admitting (or emergency room) physicians to provide additional information.1
Final Comments on Denials
Discussions of denials management often center on how an organization follows up on denials and coordinates appeals. However, if a practice can reduce denied claims proactively by improving the quality of documentation on the front end, there is an immediate positive impact on cash flow, a reduction in time-consuming (and often ineffective) follow-up activity and fewer claims written off as uncollectible.
At a time when the world seems determined to reduce radiology payments, the time has never been better for this process improvement program. Capture that pile of money!
Or look at it this way—as a physician, you accepted malpractice risk as soon as you looked at this case. Wouldn’t you like to get paid for it too? (A radiologist friend summed it up by saying “There’s nothing worse than getting sued for something you didn’t get paid for.”)
“Physician’s Documentation Guide,” MSN Healthcare Solutions, 2020, page 12
Patricia (Pat) Kroken
FACMPE, CRA, FRBMA
Prior to joining MSN Healthcare Solutions as Director of Education and Corporate Communications, Pat Kroken had nearly 30 years of experience in radiology management as both a practice manager and consultant to radiology groups, billing companies, software vendors and hospital radiology departments.
Pat has had more than 200 articles published, is a regular contributor to the Radiology Business Management Association (RBMA) Bulletin and a frequent speaker on practice management topics. She served two terms as President of the RBMA, is Editorial Advisor for the national RBMA publication, The Bulletin, and represented the “business side of radiology” as RBMA Liaison to the Radiological Society of North America (RSNA) Associated Sciences Consortium for 7 years.