How can emergency departments improve their interpretation and billing for head CT exams? A paper published in the January issue of the American Journal of Roentgenology explains that reminding physicians to include thorough clinical histories with their orders may do the trick.
Over the course of an 11-month prospective study, researchers from the University of Chicago Medical Center evaluated the clinical information and billing adequacy of 1,100 requests for head CT scans in the hospital's emergency department. They found that educating physicians about the importance of providing a satisfactory history with their imaging orders led to statistically significant improvements in the quality of head CT requisitions -- as well as faster reimbursement.
"If you don't have good quality billers and coders, inadequate histories can potentially lead to denied claims and loss in revenue," principal investigator Dr. Saad Ali told AuntMinnie.com. "After a fairly simple intervention, we improved the quality of histories for head CT exams, which allowed us to do a better job in interpretation and improved our billing efficiency."
Quality clinical history
Multiple studies have reported that providing a suitable clinical history when ordering imaging exams enhances the accuracy of image interpretation and also boosts the rate of reimbursement, according to the authors. Despite the substantiation of these findings, requests for imaging studies continue to include insufficient histories -- mainly due to a lack of awareness on the part of the referring clinicians. This can frustrate billers and coders who often need to resubmit inadequate claims.
Dr. Saad Ali from the University of Chicago Medical Center.Furthermore, recurring adjustments to coding, such as those requested by the 10th revision of the International Classification of Diseases (ICD-10) and the Medicare Physician Fee Schedule Final Rule for 2018, compound the complications and may lead to reimbursement delays or rejections.
Resolved to improve the quality of clinical information accompanying imaging orders, Ali and colleagues developed and implemented a twofold intervention. The first arm of the intervention consisted of providing the emergency department faculty with an educational program explaining how writing a proper patient history for imaging orders can result in more accurate image interpretations by radiologists and more efficient billing. The medical director of the emergency department, Dr. Thomas Spiegel, led the educational talks.
The second part involved designing and incorporating a reminder PowerPoint slide that appeared on monitors in the emergency department work area. The slide listed examples of high-quality versus low-quality clinical histories.
The researchers evaluated the effect of their intervention by comparing the quality of the clinical histories written by physicians before and after the intervention. Each image requisition received a separate score for its clinical adequacy and its billing adequacy on a scale of 0 to 2: "0" for inadequate clinical information, "1" for intermediate information, and "2" for good information, including a patient's presenting neurologic signs or symptoms. The billing manager of the radiology department established category descriptions for the billing scale.
Seven attending radiologists with a subspecialty certification in neuroradiology determined the clinical and billing scores for the 400 head CT exams requested before the intervention, from July 1 to October 31, 2015, and the 700 ordered after the intervention, from November 1, 2015, to May 31, 2016.
Improved interpretation, faster payment
The average scores for the clinical histories and the billing information on image requisitions increased by a statistically significant degree after the intervention. The number of head CT requisitions that received a high score of "2" after the intervention rose considerably for clinical adequacy and billing efficiency, with a corresponding decline in low scores of "0" and "1" (AJR, January 2018, Vol. 210:1, pp. W18-W21).
| Change in scores for quality of clinical histories for head CT orders | |||
| Mean | Preintervention | Postintervention | p-value |
| Clinical score | 1.32 | 1.43 | 0.003 |
| Billing score | 1.64 | 1.74 | 0.02 |
| Payment lag time | 75.8 days | 54.7 days | < 0.0001 |
Regarding billing, there was no significant difference in the number of CT exams reimbursed or the total dollar amount reimbursed before and after the intervention. But reimbursement for head CT exams performed after the intervention arrived approximately 21 days earlier than those performed before the intervention, due to decreased need for claim resubmissions after initial denials.
These findings, however, are limited by the subjective nature of the grading system, as well as by the natural progression in the physicians' expertise at ordering head CT exams over time, according to the researchers.
"Once the emergency room physicians realized that high-quality histories had implications into the quality of reports they received and the amount of reimbursement the hospital received, they were very amenable to improving the histories," Ali said. The intervention led to "improved interpretation and allowed the hospital to collect money faster, which, over time, essentially increases revenue of the hospital."
The researchers plan to conduct future studies to minimize the potential bias of the limitations. In particular, they plan to evaluate the effect of this type of intervention on overall patient outcomes not only for head CT exams but also for other, perhaps more complex, imaging studies throughout the hospital, Ali said.
"We hope to ultimately implement the intervention for studies ordered in other inpatient and outpatient departments," he said. "We expect the improvement to be greater for [requisitions of] more complex studies such as MRI for cancer compared to the relatively straightforward head CT."
