3:37 PMAbstract No. 192 - Standardized interventional reporting and its impact on billing, workflow, and resident training

Abstract

The purpose of this quality improvement initiative was to decrease the number of dictated reports marked for review by our coding department through a collaborative effort that would 1) identify recurrent problems/omissions in dictated reports, 2) standardize reporting to include relevant coding information, and 3) auto-populate the standardized templates to prevent the accidental use of prior outdated templates. Dictated IR studies marked for review by our hospital coding department were evaluated from 2010-2014. New standardized reporting templates for the 5 most common procedures requiring addenda were created with combined input from the coding department, SIR-approved templates, and interventional staff. New reporting templates emphasized SIR-specified information as well as all relevant coding documentation in anticipation of future ICD-10 adoption. Standardized templates were then cross-mapped with corresponding procedure codes allowing auto-population upon dictation initiation. Monthly coding addenda were reviewed pre- and post- standardized reporting template implementation. Pre-implementation, the average number of monthly studies marked for review was 14.2 (range = 3 – 31). During the four-month post-implementation period, the average number of monthly studies marked for review was 1.3 (range = 0 – 2), a statistically significant reduction utilizing the unpaired t-test (p = 0.004). Moreover, dictations marked for review utilizing the new reporting templates were subsequently analyzed and appropriate corrections made. Collaborative development of standardized reporting templates can dramatically reduce the number of required addenda thereby improving billing practices, staff workflow, and the quality and accuracy of interventional reporting. Ancillary benefits include the inclusion of relevant coding documentation for ICD-10 (laterality, chemoembolization history, etc.). Auto-population of common procedures also benefits new residents rotating through the division by providing a framework for each procedure and clearly delineating the necessary procedural information.