Physician documentation deficiencies in abdominal ultrasound reports: frequency, characteristics, and financial...

The aim of this study was to assess the frequency, characteristics, and financial impact of physician documentation deficiencies in abdominal ultrasound reports.

Using a multi-institutional coding and billing database and natural language processing software, 12,699,502 radiology reports from 37 practices were used to identify and analyze abdominal ultrasound reports. Using standard Current Procedural Terminology(®) (CPT(®)) criteria, examinations were categorized as complete (all 8 required elements documented) or limited (<8 elements). Assuming incomplete documentation, examinations were categorized as very likely, likely, or possibly complete depending on whether a minimum of 7, 6, or 5 elements were reported. Frequency and financial impact were assessed using all 3 models, and presumed documentation deficiencies were characterized.

Of 336,062 abdominal ultrasound reports by 1,136 radiologists, 252,478 (75.1%) documented all 8 elements for CPT coding as complete examinations, 25,925 (7.7%) documented 7 elements, 20,559 (5.6%) documented 6 elements, 17,521 (4.8%) documented 5 elements, and 49,579 (13.5%) documented ≤4 elements. For very likely, likely, and possibly complete examination models, deficiencies were present in 9.3%, 15.5%, and 20.2% of cases, resulting in 2.5%, 4.2%, and 5.5% decreases in legitimate professional payments. The spleen (41.2%) was the most frequent element neglected. Of 106,168 examinations titled complete, only 92,824 (87.4%) fulfilled complete CPT criteria. In 221,887 (60.6%), examination titles were clearly erroneous or too ambiguous for code assignment. Documentation deficiencies were less frequent for high-volume radiologists (P < .0001).

Incomplete physician documentation in abdominal ultrasound reports is common (9.3%-20.2% of cases) and results in 2.5% to 5.5% in lost professional income. Structured reporting may improve documentation and mitigate lost revenue.