Obtaining Relevant Radiology Request

Information

University of Wisconsin Hospital and Clinics University of Wisconsin-Madison, Wisconsin

Quality Care

demands Quality Information

Problem

Lack of accurate, salient clinical information on radiology requests may lead to:

» Suboptimal performance/interpretation of exam » Coding and billing inaccuracies» Potential medico-legal implications

Who should be gatekeeper?

Vision

Identify need for improvement for benefit of organization

Root causes Identify solutions Educate physicians and staff Involve institution in ongoing compliance

Team Members Quality Improvement Department (Team Leader) Radiologist - Body Imaging Laboratory Medicine Physician Information Systems Physician Director, Emergency Department Radiology Administrator Transplant Floor Unit Clerk Unit Clerk Educational Coordinator Information Systems Project Leader Oncology Program Assistant Management Engineer Ad Hoc Team Members (Physician Billing Mgr, UWHC Fiscal Mgr)

Goal

To increase to 90% the number of radiology requisitions with accurate and appropriate salient clinical information.

Suboptimal Exams/Interpretations

Improvements Would Result In: Technologists focusing on area of concern Quality radiologist interpretation Better communication between referring

clinician and radiologist

Coding and Billing Inaccuracies

Develop documentation standards for Radiology, Lab, Pharmacy, ECG, etc

Potential Medico-Legal Implications Medicare requirements

» Federal Register 42CFR424.10 - 11 Medical necessity

» all procedures (radiology and non-radiology) must have a clinical condition to be a payable service*

Frequency » must be appropriate for clinical condition*

(*refer to Section 18.14(a)(2) and 18.35(a)(2) of the Social Security Act)

Implications of MedicareNon-Compliance

Over $33K lost/written off in monthly Medicare charges

If reason for exam not substantiated, cannot bill

HCFA audit could result in:– Allegations of Fraud– Fines

Root Causes

Clinician verbal/written order interpreted incorrectly

Order transcribed/entered into system incorrectly

Radiology handling of information

Solutions

Developed an Acronym (CYA) to Assist Clinicians in Remembering Required Information» C Current diagnosis» Y Why you want the exam » A Already known history relevant to the study

being requested

Solutions (cont’d) Educated clinicians, radiologists and staff Visual reminders Incentives to house staff for providing

adequate information Mandated correct pager numbers be

provided

General Ordering Rules

DO NOT give the following as the ONLY information» “R/O” (alone)

» “Possible”

» “Probable”

» “Suspected”

» “Pre-Op”

» “Screening”

DO list specific clinical dx, signs, sx, or patient complaints» “RLQ pain”

» “malignant renal hypertensive disease”

» “SOB/cough, R/O pneumonia”

» “Accident--give type”

Benefits of “CYA” Ordering

Documents “medical necessity” of ordered test Quality patient care Good customer service Prevents unnecessary phone calls Correct coding and billing benefits entire

organization’s bottom line

Implementation

Piloted program on Hematology/Oncology Inpatient unit» Educated clinicians and staff» Developed a team logo “Quality Care Demands

Quality Information”

Quality Care demands

Quality Information

Implementation (cont’d)

Target inpatient implementation (2 units) completed July, 1997– Pre-implementation compliance: 52%– At peak of our efforts: 67%

House-wide ambulatory clinic implementation initiated February, 1998

Internal Medicine, Surgery and Oncology Clinic Implementation

Percent Compliance of CYA Program - Pre and Post Implementation

64.4% 65.3%

49.9%

74.5% 75.6%

64.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

CurrentDiagnosis

Why AlreadyKnow nHistory

CYA Variables

Perc

en

t C

om

plian

t

Pre-implementation2/2 through 2/14

Post-implementation2/23 through 2/28

Implementation (cont’d)

Gave ‘report card’ of what was needed to bring in compliance

Re-checks and follow-up done after implementation

Implementation, Phase B

Compliance fell, implemented Phase B “No Data, No Study” Project employees hired Notified clinicians that lack of compliance

would result in refusal to study effective July 1, 1999

Lessons Learned

Identify specific problems Team should have physician/staff make up Identify gatekeeper early in process Obtain buy-in from department chairs Identify areas of non-compliance, focus

education Educate in large setting and one-on-one

Lessons Learned (cont’d)

Provide specific feedback Pilot an “easy” area Present updates and findings to hospital

administration, Compliance Committee Be prepared to take hard approach (“no

data, no study”) Orient new medical staff

How Are We Doing Now?

Two-years post education and implementation

Compliance Rate = 98% (ambulatory procedures only)

University of Wisconsin-MadisonMargaret L. Birrenkott, MBA

Administrator & Director, Business Services

Department of Radiology

Education Team Members:Kris Leahy-Gross, RN

Fred Kelcz, M.D.Carol Hassemer