When they are given the clearest health picture possible, radiologists can identify the appropriate paths of recovery to recommend to referring physicians. Without accurate clinical documentation, their jobs become much more difficult and could impact patients' outcomes.
According to AuntMinnie.com, incomplete documentation leads to issues with payments for diagnostic radiology services. Government agencies like the U.S. Centers for Medicare and Medicaid Services advised health care providers that complying with documentation requirements helps avoid errors in reimbursements.
In July, the CMS summarized the issues with incomplete medical information in its Medicare Quarterly Provider Compliance newsletter. After conducting a program review on Comprehensive Error Rate Testing, the agency uncovered inconsistencies related to vertebroplasty and kyphoplasty procedures. The CERT contractors are responsible for calculating the Medicare fee-for-service improper payment rates of medical imaging practices. During an audit of randomly selected claims, the program found that insufficient documentation accounted for roughly 97 percent of inaccurate payments on claims submitted by hospitals and other health care providers.
Missing pieces of information included a lack of physician signature on exam notes, missing relevant medical history and incomplete diagnoses. The findings from the CMS review indicate that radiologists need to improve documentation to maintain compliance with all regulations. When requested, digital imaging providers have to conduct complete clinical documentation for the tests they perform.
The adoption of electronic health records software would help practices take down more detailed information for each patient.
Optimizing documentation with EHRs
The implementation of EHR software may be considered time-consuming and expensive to some providers, but the improvements to documentation strategies balance out any negatives.
For example, many new EHR products currently breaking into the market come equipped with voice recognition software, Medical Economics explained. Doctors are concerned about spending too much time staring at laptops and typing instead of talking directly with patients. By including speech recognition, radiologists and other physicians are able to freely converse in the reading room without feeling distracted by a computer screen.
An added benefit of utilizing EHRs in the radiology practice is the ability to empower patients to be more engaged in their care. After documenting information, doctors can have patients review the data to ensure its accuracy and participate in clinical decision-making opportunities. When physicians are looking to successfully attest to Meaningful Use in accordance with the CMS, getting patients involved in health care is critical to earning incentives through the federal program.
Contact Viztek for more information.
Ronny Bachrach
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