JACR: Better rad documentation means better reimbursement

Radiologists looking for more success in getting reimbursed for the services they perform should provide better documentation, according to an article in the September issue of the Journal of the American College of Radiology.

"When radiologists believe they're not collecting as much as they should, some introspection is usually in order," wrote Richard Duszak, MD, of Midsouth Imaging and Therapeutics in Memphis, Tenn. “Not infrequently, the billing company is doing an adequate job—with the reports they get.”

If a radiologist doesn’t document what’s been done, the billing company can’t help him get paid, said Duszak, adding that good documentation isn’t that difficult, “it just takes commitment."

Duszak examined several areas where radiologists can get better reimbursement results by providing better documentation, such as:

1. Clinical History: Radiologists need to provide this information in their insurance claims, and the best way to get that information to coders and billers is to dictate it. “Including this information in your report can mean the difference between getting paid and not,” wrote Duszak.

1. Body Part: Radiologists need to be as specific as possible in identifying body parts they are imaging. Duszak suggested that “for all studies, state what body part was imaged, and whenever possible, do it in simple terms that coders and auditors will understand.”

1. Number of Views: It’s important to document this thoroughly. According to Duszak, accurately documenting whether a chest study is one view or two views can translate into a 25 percent difference in collections between those radiologists who document accurately and those who do not.

1. Organs Imaged: The difference in reimbursement between a limited and a complete abdominal ultrasound study is about 35 percent, said Duszak, “so if you perform a full examination, make sure you report one.”

1. Contrast: For studies such as MRI of the brain, said Duszak, the dollar difference between a noncontrast study and one performed before and after contrast is almost double. So radiologists need to get in the habit, for all CT and MRI studies, of reporting them “with intravenous contrast” or “before and after intravenous contrast” when appropriate.

In conclusion, wrote Duszak, a radiologist’s report not only provides diagnostic information, but is the basis on which he or she ultimately gets paid. “Radiologists who pay attention to reimbursement-specific details stand to get paid better than those who don't,” he concluded.