By Cynthia E. Keen, AuntMinnie.com staff writer
November 18, 2010

Thursday, December 2 | 12:15 p.m.-12:45 p.m. | LL-INS-TH3A | Lakeside Learning Center
To reduce inaccuracies in documentation of contrast administration and to improve billing accuracy, the San Diego Veterans Affairs Healthcare System created an audit tool. The results have been nothing short of remarkable.

In this poster presentation, Amilcare Gentili, MD, chief of radiology services and professor of clinical radiology at the University of California, San Diego School of Medicine, will explain how his department developed and utilizes a semiautomatic tool to identify CPT codes corresponding to eligible contrast procedures of examinations.

The type, concentration, and amount of contrast are extracted from the report and entered into separate database fields. The exam is flagged if no contrast documentation is found.

The tool is easiest to use with standard report templates, according to Gentili. But even with free text, the tool is able to extract the exposure times with high accuracy or classify the report as missing documentation of contrast administration.

"About two years ago, before we began to use the tool, we did not report the amount and concentration of contrast. With the tool, over 95% of reports have correct documentation," Gentili told AuntMinnie.com.

"Each month, we identify a few cases that were entered by the technologists incorrectly," he said. "Either the study was coded with contrast, but performed without it. Or, it was entered without contrast, but contrast was used. As billing is based on the procedure entered into the radiology information system, this can lead to incorrect billing. Catching an error at the outset improves our billing accuracy and contributes to improving efficiency in this process."





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