Structured reporting cuts coding errors, facilitates full reimbursement

Incomplete radiology reports that lead to inappropriate coding and, thus, hits to reimbursement can be headed off by structured reporting, according to a study conducted at NYU Langone School of Medicine and published online Dec. 24 in the Journal of the American College of Radiology.

Kristine Pysarenko, MD, Michael Recht, MD, and Danny Kim, MD, describe their work testing structured reporting for such capabilities after their billing department made a discovery: The billers found that many complete abdominal ultrasound exams had been improperly coded—and subsequently reimbursed as limited exams—due to the inadvertent omission of important elements from radiology reports.

Langone’s abdominal imaging subspecialists developed a tabulated template for dictating abdominal ultrasound reports. The template incorporated input from published guidelines and the billing department. It listed each organ on its own line and integrated with the radiology department’s dictation software. The team rolled it out in October 2013.

For the study, the billing department retrospectively gathered digital coding records for complete abdominal ultrasounds performed at a Langone outpatient imaging center between January 2013 and September 2015.

Comparing the before-and-after billing outcomes using a mixed-model analysis of variance, and excluding ultrasound exams that were appropriately coded as limited, the researchers found that the average number of erroneously coded limited abdominal ultrasounds dropped from 14.67 to 2.58 per month after the initiation of structured reporting. This represented a statistically significant decrease (P = .002).

In their discussion, the authors note that ICD-10 has made it harder than ever to ensure correct and accurate coding.

“Structured reporting can help ease this burden by providing a more standardized and complete report and aids in reminding radiologists to include all necessary elements in their reports,” they write. “Furthermore, the standard format allows coders to easily navigate reports and find the relevant information, as it is in the same location every time.”

The result is more accurate coding and, with it, appropriate reimbursement, they point out. “But most important, [structured reporting] ensures that we are providing complete information to referring physicians.”

The authors acknowledge several limitations in their study design, including the lack of a way to correct for the degree to which the improvement would have occurred absent structured reporting. A concerted effort to minimize incomplete reporting was already underway throughout radiology prior to the structured reporting go-live, they note.

Further, although they found great value in structured reporting for abdominal ultrasound exams, “careful consideration should be given to the value of structured reporting in different modalities before widespread adoption within a department.”

Still, the study showed that structured reporting “can be an effective tool for ensuring the completeness of radiology reports and maximizing appropriate coding and reimbursement,” as the authors conclude. “Departments may benefit from an internal audit of their claims to identify those examinations that suffer the most impact of inappropriate coding and may benefit from structured reporting.”