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December 3, 2024
An interview with Laura Manser, CPC, CDEO, CIRCC, CPMA, CEMC, RCC, Director of Provider Education

Tell us about your role as the director of physician education and how long you have been with PBS.
I’ve been with the company for 24 years. My role involves identifying areas for documentation improvement and providing targeted education to providers to reduce downcoding, medical necessity denials, and addendum requests. Through ongoing audits, I ensure that physician documentation stays compliant and accurately captures all revenue owed.

Why are you so passionate about physician education?
I’m passionate about physician education because it has a direct impact on both patient care and the financial health of a practice. When physicians understand how to document accurately and effectively, it reduces errors, downcoding, and denials, which ensures they are properly compensated for their work. More importantly, it helps streamline care, ensuring that necessary procedures and treatments are covered and paid without delays. I’ve seen firsthand how the right education can make a huge difference in compliance, revenue, and patient outcomes, and that’s why I’m so committed to this work.

You have a lot of certifications behind your name. What do they all mean?
The certifications I hold reflect my expertise in various areas of coding, auditing, and compliance. Each certification reflects my ability to support physicians and the organization in maintaining compliance, reducing errors, and optimizing revenue.

  1. CPC (Certified Professional Coder) shows my proficiency in medical coding across multiple specialties, ensuring accuracy in coding and billing.
  2. CPMA (Certified Professional Medical Auditor) demonstrates my ability to conduct thorough audits to identify areas for improvement in documentation and coding practices.
  3. CEMC (Certified Evaluation and Management Coder) emphasizes my expertise in E/M coding, which is critical for proper billing of patient visits and services.
  4. CDEO (Certified Documentation Expert Outpatient) focuses on improving outpatient documentation to ensure accuracy and compliance.
  5. CIRCC (Certified Interventional Radiology Cardiovascular Coder) highlights my specialized knowledge in interventional radiology and cardiovascular coding, a complex and highly regulated area.
  6. RCC (Radiology Certified Coder) demonstrates my expertise in radiology coding, essential for accurate coding and compliance in this field.

Why are Clinical Documentation Improvement (CDI) programs for radiology groups so important?
CDI programs are crucial for radiology groups because they ensure that the documentation accurately reflects the complexity and scope of the procedures performed. Radiology coding rules can be complex and often involves highly technical and intricate procedures, and without precise documentation, there is a risk of downcoding, medical necessity denials, or missed opportunities for reimbursement. A strong CDI program helps radiologists communicate the full clinical picture, which not only improves coding accuracy but also supports compliance, reduces addendum requests, and ensures the group captures every dollar owed for their services. Ultimately, it strengthens both patient care and the financial health of the practice.

What is a common misconception about coding?
A common misconception about coding is that it’s just data entry. In reality, coding requires a deep understanding of anatomy, physiology, medical procedures, medical terminology, coding rules and payer rules to ensure accurate coding and compliance. For example, in radiology, the correct use of modifiers relies on understanding both the anatomy involved and the specifics of the procedure, which can make the difference between full reimbursement and a denial.

Why is radiology personal to you?
For the past 24 years, I’ve dedicated my career to the business of radiology. My passion for this field is personal, not just professional. It’s why my husband, who is currently in medical school, aspires to become a radiologist.

At PBS, we value the work you do as radiologists. We understand the challenges you face—being overworked, underpaid, and dealing with shortages. My goal, as Director of Provider Education, is to ensure your documentation is accurate, compliant, and that you’re capturing every dollar you’ve earned. We take your financial goals and the well-being of your practice as seriously as you do. I am a PBS expert, and this is why radiology is not just my profession, but my passion.

Laura Manser CPC, CDEO, CIRCC, CPMA, CEMC, RCCis the Director of Provider Education at PBS Radiology Business Experts. With 24 years of radiology experience, she is a trusted subject matter expert in coding, auditing, and documentation improvement. A dedicated educator, Laura trains coders and physicians to enhance coding accuracy, documentation quality, compliance, and revenue optimization through tailored programs. Holding multiple certifications from AAPC and RCCB, Laura is known for her proactive leadership, strong work ethic, and commitment to excellence in radiology.

 

 

 

November 8, 2024
By: Angie Wardlaw, Director of Client Services

Introduction

After two decades in healthcare operations and revenue cycle management, I’m thrilled as I continue a new journey as Director of Client Services at PBS. As I reflect on my career journey through radiology and multi-specialty physician practice groups in North Carolina, I’m excited to bring my experience and passion for healthcare excellence to my role in Revenue Cycle Management.

My Leadership Philosophy

Throughout my career, I’ve embraced the principle that true leadership isn’t about being in charge—it’s about taking care of those in your charge. As a servant leader, I believe in empowering team members and ensuring they have everything they need to succeed. I’ve found that when we focus on growing and supporting each other, innovation naturally follows and teams consistently achieve extraordinary results.

Partners in Revenue Cycle Success

One of the aspects I’m most passionate about in my role is being a true extension of our clients’ billing offices. Having worked extensively in healthcare revenue cycles, I understand the complexities and challenges our clients face daily. I don’t see PBS as just a service provider—we’re genuine partners in our clients’ success. When our clients face challenges, I believe in facing them together, finding creative solutions that drive real results.

Rolling Up My Sleeves

If there’s one thing my colleagues know about me, it’s that I’m never afraid to roll up my sleeves and dive deep into challenges. I believe the best solutions come from getting your hands dirty and truly understanding the problem from all angles. Whether it’s streamlining workflows, implementing new technologies, or resolving complex billing issues, I’m always ready to jump in and work alongside our teams to find effective solutions.

Building Strong Relationships

In my experience, the foundation of any successful business partnership is strong relationships. I take pride in fostering meaningful connections with both our team members and clients. To me, it’s not just about professional interactions—it’s about understanding each stakeholder’s unique needs, challenges, and goals. This understanding allows us to develop solutions that aren’t just effective for today but sustainable for the long term.

My Vision for the Future

As I step into my role at PBS, I’m excited about the opportunities ahead. Healthcare is constantly evolving, and so are the needs of our clients. I’m committed to ensuring that PBS continues to be at the forefront of healthcare revenue cycle management, delivering innovative solutions while maintaining the personal touch that makes us different.

I believe in being proactive rather than reactive, in finding solutions rather than dwelling on problems, and in building partnerships that stand the test of time. My goal is to help our clients navigate the complexities of healthcare revenue cycles while maximizing their operational efficiency and financial outcomes.

Looking Forward

I’m genuinely excited to be part of the PBS team and to work closely with our clients. Together, I know our team can achieve great things for our clients and continue to strengthen PBS’s position as a leader in healthcare revenue cycle management.

Angie Wardlaw is a results-oriented, purposeful leader with over 20 years of accomplishments in healthcare operations and revenue cycle management. Angie is known for her creative and solution-driven skills and leads by building solid relationships with internal and external customers. She is passionate about helping others, streamlining processes, and producing effectual transformations. Before joining PBS as a Client Services Manager, Angie has been a vital member of the executive leadership team in both operational and revenue cycle roles in radiology and multi-specialty physician practice groups in North Carolina.

October 25, 2024
Source: Center For Internet Security (www.cisecurity.org)

Cybersecurity is essential in today’s digital age as it protects sensitive data, systems, and networks from cyber threats. As we increasingly rely on technology for everything from personal communication to critical infrastructure, cybersecurity helps safeguard against risks such as data breaches, identity theft, and financial loss. Here are 11 tips to make your work and home environment safer, from the Center For Internet Security.

Tip 1: Set Some Cyber Defense Priorities
Consider the following questions to begin formulating a cybersecurity roadmap that works for you:

  • What are your cybersecurity and cyber defense goals?
  • Have you identified which devices and data you want to protect?
  • What level of security do they need?

Tip 2: Think Before You Click
Hover over a link to reveal the destination URL. If it looks different from the hyperlinked text, don’t click on it.

Tip 3: Don’t Get Phished
Phishing attacks often use a sense of urgency to trick you into clicking on a link or opening an email attachment. Don’t fall for it. Forward any suspicious message to your IT and/or your security department at work. If you receive a suspicious email on your personal device, delete it and consider blocking the domain.

Tip 4: Go Beyond the Password
Cyber threat actors easily crack “password”, “admin”, and other dictionary-based passwords. For stronger account security, protect your accounts with a biometric passcode or a unique alphanumeric passphrase with symbols.

Tip 5: If It Matters, Use Multi-Factor
Protect your accounts with authentication methods from at least two of the following categories:

  • Something you know: A passphrase or swipe pattern
  • Something you are: Biometrics, fingerprint
  • Something you have: An authentication app on your phone or an ID badge.

At a minimum, use two-factor authentication (2FA) for accounts and devices that handle sensitive data.

Tip 6: Keep It Fresh
Always install the latest updates for your operating system, browser, and any applications installed on your device. Cyber threat actors (CTAs) try to use known vulnerabilities to access your devices and/or other devices that are connected to the same network. Don’t let yourself (or your organization) become an easy target.

Tip 7: Reflect, Then Connect
Before connecting to a public or unfamiliar Wi-Fi network, use a virtual private network (VPN). A VPN creates an encrypted, private web connection, thus minimizing the risk of data exposure.

Tip 8: Shop Smart, Shop Secure
Protect sensitive banking data by only shopping on sites you trust. Never save your card information where it could be stolen and used later. Also, make sure to monitor your payment card records for unfamiliar charges.

Tip 9: Avoid Configuration Confusion
Securely configure your computer, printer, smartphone, and other web-connected devices in your home and in your office. That way, you’ll protect each of your devices with the strongest security settings possible.

Tip 10: Don’t Be the Bully
When online, remember to be thoughtful and to use polite language. Sharing someone’s private personal information online, also known as “doxxing”, is never okay and may get you in legal trouble.

Tip 11: Charge with Caution
Don’t plug your mobile devices into any unfamiliar outlet to avoid a possible juicejacking attack. If you’re worried about running out of battery, bring a backup power bank or charge your device using your own charging cable and wall outlet.

October 22, 2024
Source: 2025 CPT Anticipated Code Changes | American College of Radiology (acr.org)

2025 CPT Coding Changes – Radiology

As part of the 2025 CPT code changes, several new codes and revisions will impact radiology effective January 1, 2025. Below is an overview of key updates that radiology practices should be aware of:

New Codes

  • MRI Safety Procedures: Six new codes will be introduced in the MR Safety Implant/Foreign Body Procedures subsection. These codes (7XX00-7XX05) will cover services related to implant or foreign body evaluations, safety consultations, electronics preparation, and implant positioning for MRI studies. This section will fall under Radiology/Diagnostic Radiology (Diagnostic Imaging).
  • MRI-Monitored Transurethral Ultrasound Ablation (TULSA): New codes (5X006-5X008) will be introduced to cover MRI-monitored TULSA, a procedure that utilizes robotically driven thermal ultrasound for prostate tissue ablation in prostate cancer treatment. These codes will include treatment planning, insertion, and ablation of prostate tissue.
  • MRI-Guided High-Intensity Focused Ultrasound (MRgFUS): Code 0398T will be converted from Category III to Category I. This code covers MRgFUS, which is a non-invasive procedure to ablate tissue within the skull. Three new codes will replace 0398T, including codes for treatment planning, insertion, and tissue ablation. 
  • Transcranial Doppler Studies: Three new add-on codes will be introduced to report various transcranial Doppler procedures:
        • Vasoreactivity study
        • Emboli detection without intravenous microbubble injection
        • Venous-arterial shunt detection with intravenous microbubble injection
        • Code 93893 will be revised for venous-arterial shunt detection, and code 93890 will be deleted. The transcranial Doppler code range includes 93886, 93888, 93892, and 93893. 
  • Percutaneous RF Ablation of Thyroid: A new code will be introduced to report percutaneous radiofrequency ablation of the thyroid under imaging guidance, along with an add-on code for ablating additional thyroid nodules.
  • Fascial Plane Blocks: Six new codes will be created for reporting specific fascial plane block injections or infusions in various regions:
        • Codes 64486-64489 will be revised to specify transverse abdominis plane (TAP) blocks, and additional guidelines will reflect these changes. These codes cover both unilateral and bilateral TAP blocks and continuous infusions.

Revisions

  • Vascular Procedure Guidelines: Revisions will clarify that add-on code 75774 for angiography (selective, each additional vessel studied) can now be reported for both arteries and veins. Cross-references for angiography and catheterization codes, such as 75600-75756 and 36215-36248, will be deleted.

Deletions

  • MRgFUS Code: Code 0398T for MRgFUS will be deleted and replaced by the new Category I codes.
  • Transcranial Doppler Code: Code 93890, which covered certain transcranial Doppler studies, will be deleted.
  • Telemedicine Office Visits: Codes 99441-99443 for telephone evaluations and management services will be removed, as new telemedicine office visit codes will replace them.

Telemedicine Services

A new subsection within Evaluation and Management (E/M) will include 17 new telemedicine codes. These will cover telemedicine services for both audio-visual and audio-only visits. Additionally, a new virtual check-in code will be introduced to evaluate whether an in-person visit is required, similar to HCPCS code G2012. The deleted codes will include 99441, 99442, and 99443.

Category III Extensions

Several Category III codes scheduled to sunset in 2025 will be extended until December 2030. These include:

  • 0071T and 0072T: Focused ultrasound ablation of uterine leiomyomata with MR guidance
  • 0075T and +0076T: Transcatheter placement of extracranial vertebral artery stents
  • 0200T and 0201T: Percutaneous sacral augmentation, unilateral and bilateral injections
  • 0554T-0558T: Bone strength and fracture risk analysis using finite element data from CT scans
  • 0559T and +0560T: 3D-printed anatomical models
  • 0561T and +0562T: 3D-printed anatomical guides

July 27, 2024
By: Laura Manser, CPC, CDEO, CIRCC, CPMA, CEMC, RCC, Director of Provider Education

Source: https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-the-July-27-2024-Issue/ACR-Provides-Detailed-Summary-of-2025-Medicare-Physician-Fee-Schedule-Proposed-Rule

Overall Summary of 2025 Medicare Physician Fee Schedule Proposed Rule

  • CMS has proposed changes to the Medicare Physician Fee Schedule (MPFS) for 2025, which could have varying impacts on different areas of radiology. For general radiology, nuclear medicine, and radiation oncology, the overall financial impact is expected to remain neutral, with no significant changes in reimbursement. However, interventional radiology might experience a slight decrease of about 2% if the proposed rule is finalized.
  • It’s important to note that this assessment does not account for the expiration of the temporary payment increase provided by the Consolidated Appropriations Act of 2024. The proposed conversion factor for 2025 is $32.3562, which is approximately 2.8% lower than the 2024 conversion factor of $33.2875. This reduction could affect overall payments across all radiology services.

Conversion Factor and Impact on Radiology

  • Conversion Factor: CMS proposed a conversion factor of $32.3562 for 2025, which is slightly lower than the 2024 rate of $33.2875.
  • Impact on Radiology: Overall, CMS expects no change for radiology, nuclear medicine, and radiation oncology, but interventional radiology could see a 2% decrease if the rule is finalized.

Coverage for Colorectal Cancer Screening

  • New Coverage: CMS is proposing to cover Computed Tomography Colonography (CTC) for colorectal cancer screening. This test is less invasive and easier on patients compared to traditional colonoscopies.
  • Barium Enema Removal: CMS plans to stop covering the barium enema procedure for colorectal cancer screening, as it’s no longer considered the best option.

Technical Component Reimbursement

  • CT Colonography: The technical component of CT Colonography might be capped at $106.30, lower than the proposed Medicare Physician Fee Schedule rate of $528. If this is finalized, the lower rate will apply across both hospital and freestanding settings.

Practice Expense Updates

  • Price Updates: CMS is proposing updates to the prices of certain supplies and equipment used in radiology, based on new invoices. They are also reviewing how to best update these prices in the future.

New CPT Codes and Procedures

  • MRI-Monitored Prostate Treatment: Three new codes were introduced for MRI-monitored ultrasound ablation of the prostate. These codes are expected to have work values of 4.05, 9.80, and 11.50.
  • Thyroid Nodule Ablation: Two new codes for thyroid nodule ablation procedures are proposed, with work values of 5.75 and 4.25.
  • MR Safety Procedures: Six new codes were added for safety procedures related to MRI for patients with implanted medical devices. These procedures help ensure patient safety during MRI scans.

Global Surgery Payment Accuracy

  • Post-Operative Care: CMS is concerned that some post-operative visits included in global surgery payments are not being performed. They propose that doctors use special codes when transferring care during the post-operative period to prevent overpayments.

Supervision Flexibility

  • Virtual Supervision: CMS is extending the flexibility to allow doctors to supervise certain procedures via real-time audio and video through 2025. They are considering making this a permanent option for some lower-risk services.

Quality Payment Program (QPP) Updates

CMS is proposing several changes to the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) for the 2025 performance year. For the 2025 performance period, CMS proposes to maintain the 75-point performance threshold. No changes are proposed for the MIPS adjustment.

  • Removal of Measure #436: CMS plans to remove Measure #436, which focuses on “Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques,” from the list of available measures. This measure is being removed as it is considered duplicative of the following newly added measure in the Diagnostic Radiology set.
  • Addition of Measure #494: A new measure, Measure #494, titled “Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults,” will be added to replace the removed measure. Notably, this new Diagnostic Radiology measure is an eCQM, which means it will not be reportable as a traditional MIPS CQM.
  • MIPS Value Pathways (MVPs): CMS is moving towards using MVPs instead of the traditional MIPS program. These pathways are designed to simplify reporting and improve care coordination.
  • New Requests for Information: CMS is asking for public feedback on how to improve care in ambulatory specialty settings and how to fully transition to MVPs.

These updates reflect CMS’s ongoing efforts to improve the accuracy and relevance of the measures used in MIPS, ensuring that the program continues to drive quality improvement and care coordination across the healthcare system.

Changes to Radiology-Specific Codes

  • Misvalued Services: CMS is reviewing and seeking feedback on several radiology codes to ensure accurate payment. These include codes related to fine needle aspiration biopsies and sacroiliac joint procedures.

Final Notes

  • Stakeholder Feedback: CMS is actively seeking feedback from medical professionals and organizations to refine these proposals before finalizing them.

Laura Manser, CPC, CDEO, CIRCC, CPMA, CEMC, RCC, is the Director of Provider Education at PBS Radiology Business Experts. With 24 years of experience in radiology, specializing in professional and hospital coding and auditing, Laura is a valuable resource for physicians and coding teams nationwide. She is dedicated to accurate and compliant medical coding and to developing clinical documentation improvement programs within radiology practices. Laura enjoys educating coders and physicians to enhance coding accuracy and documentation, optimizing revenue. Known for her proactive leadership, strong work ethic, and commitment to excellence, Laura holds multiple coding certifications from AAPC and RBMA. 

July 25, 2024
By: Laura Manser, CPC, CDEO, CIRCC, CPMA, CEMC, RCC, Director of Provider Education

In our ever-evolving healthcare landscape, teleradiology continues to play a crucial role. Let’s dive into some key points about Evaluation and Management (E/M) visits performed via telemedicine, with a focus on new patient encounters.

New Patients: More Than Just a Phone Call

Telephone-Only Visits: Not billable for new patients
Required: Audio-visual communication

Why the Distinction? The Centers for Medicare & Medicaid Services (CMS) and most commercial payers mandate audio-visual communication for new patient telehealth encounters. This requirement ensures:

  • A comprehensive evaluation
  • Establishment of a physician-patient relationship
  • Higher quality of care

Established Patients: Some Flexibility

Audio-only visits may be permissible
Always verify specific payer policies

Coding and Documentation: Key to Compliance

When documenting and coding telemedicine E/M visits:

  1. Use appropriate telehealth place of service codes
  2. Apply required modifiers indicating remote service
  3. Document technology used (e.g., “visit conducted via secure video conferencing”)
  4. Obtain and document patient consent for telehealth services

Latest Guidance

The American College of Radiology (ACR) emphasizes the importance of state-specific telehealth laws and regulations. Some states have permanent telehealth policies, while others are still operating under COVID-19 emergency orders.

Remember: Payer policies can differ from Medicare rules. Always check the most current guidelines from each payer.

Tip: The ACR recommends radiologists ensure they’re licensed in the state where the patient is physically located during the telehealth visit to comply with state medical board requirements.

By staying informed and adhering to these guidelines, radiology practices can effectively navigate the telehealth landscape, ensuring proper reimbursement and maintaining compliance.

Resources:

  1. Centers for Medicare & Medicaid Services (CMS) “Medicare Telemedicine Health Care Provider Fact Sheet” https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
  2. American College of Radiology (ACR) “ACR Radiology Coding Source™” https://www.acr.org/Practice-Management-Quality-Informatics/Coding-Source
  3. American Medical Association (AMA) “AMA Telehealth quick guide” https://www.ama-assn.org/practice-management/digital/ama-telehealth-quick-guide
  4. Medicare Learning Network (MLN) “Telehealth Services” Booklet https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf
  5. Health and Human Services (HHS) “Telehealth: Delivering Care Safely During COVID-19” https://www.hhs.gov/coronavirus/telehealth/index.html

Note to Our Readers: Please note that while these are authoritative sources, healthcare regulations and guidelines can change rapidly. We encourage our readers to verify the most up-to-date information, especially regarding state-specific regulations and individual payer guidelines.

Laura Manser CPC, CDEO, CIRCC, CPMA, CEMC, RCC, is the Director of Provider Education at PBS Radiology Business Experts. With 24 years of radiology experience, she is a trusted subject matter expert in coding, auditing, and documentation improvement. A dedicated educator, Laura trains coders and physicians to enhance coding accuracy, documentation quality, compliance, and revenue optimization through tailored programs. Holding multiple certifications from AAPC and RCCB, Laura is known for her proactive leadership, strong work ethic, and commitment to excellence in radiology.

June 7, 2024
By: Laura Manser, CPC, CDEO, CIRCC, CPMA, CEMC, RCC, Director of Provider Education

Unlock the Full Potential of Your Radiology Practice with Documentation Excellence

In the ever-evolving landscape of healthcare, the precision of radiology report documentation has never been more critical. As a physician, you strive to provide the best care for your patients, but are you ensuring that your practice’s documentation standards are meeting the mark for optimal reimbursement?

Why Documentation Improvement Matters

1. Reduce Denials and Downcoding: Precise and detailed documentation directly correlates with a decrease in claim denials and downcoding by coders. Inadequate documentation leads to lost revenue, consuming valuable time and resources to rectify.

2. Maximize Reimbursement: Enhanced documentation ensures that all provided services are accurately captured and billed, leading to increased revenue. It’s not just about getting paid; it’s about getting paid what you rightfully deserve.

3. Compliance and Quality Care: High-quality documentation supports compliance with regulatory standards and promotes better patient care by ensuring clarity and detail in every report.

How to Participate in Documentation Improvement

1. Education and Training: Engage with our series of modality-specific documentation education. Designed to enhance your understanding and implementation of best practices in radiology reporting, our program is your first step towards documentation excellence.

2. Continuous Quality Improvement: Adopt a culture of continuous improvement within your practice. Our regular audits and feedback mechanisms can help identify areas for improvement, ensuring your documentation standards evolve alongside industry best practices.

By focusing on documentation improvement, your practice can achieve a dual benefit: enhanced patient care and optimized revenue. Our educational program offers a comprehensive approach to elevate your radiology report documentation. Embrace the opportunity to rise to the pinnacle of radiology excellence. Let’s transform your documentation practices for a brighter, more profitable future.

Your journey to documentation excellence begins here.

Laura Manser CPC, CDEO, CIRCC, CPMA, CEMC, RCC, is the Director of Provider Education at PBS Radiology Business Experts. With 24 years of radiology experience, she is a trusted subject matter expert in coding, auditing, and documentation improvement. A dedicated educator, Laura trains coders and physicians to enhance coding accuracy, documentation quality, compliance, and revenue optimization through tailored programs. Holding multiple certifications from AAPC and RCCB, Laura is known for her proactive leadership, strong work ethic, and commitment to excellence in radiology.

June 6, 2024
By: Laura Manser, CPC, CDEO, CIRCC, CPMA, CEMC, RCC, Director of Provider Education

Introduction

In the specialized field of radiology, precise and complete documentation is not just a regulatory requirement—it is crucial for securing proper reimbursement and reducing the risk of denials. A well-structured Clinical Documentation Improvement (CDI) program tailored for radiology groups can significantly prevent down-coding and enhance the justification of medical necessity, key components in mitigating denials. This article provides a practical, step-by-step guide for radiology groups to implement an effective CDI program focused on these goals.

Step 1: Define Specific Objectives

The first step in setting up a successful CDI program is to set clear and focused goals. For radiology groups, these goals should specifically address:

  • Prevention of Down-Coding: For example, you might aim to reduce the rate of down-coded claims by 15% within the first six months.
  • Improvement of Medical Necessity Documentation: Often, physicians order tests, but the medical necessity is not clear. An example goal could be to achieve a 95% clean claims rate by ensuring all imaging orders include proper medical necessity documentation, reducing denials related to insufficient justification by 20% within a year.

Clinical documentation improvement is a proactive measure, which requires consistency and attention to detail. You should assume that all clinical documentation will be scrutinized at some point. Quantifiable and achievable goals are essential as they provide measurable targets that can be tracked and evaluated over time. Additionally, these goals should be directly tied to reimbursement outcomes, ensuring that improvements in documentation translate into tangible financial benefits. For instance, achieving a higher clean claims rate can directly lead to faster payment cycles and reduced administrative costs associated with claim rework and resubmission.

From a Payor Perspective:

  • Compliance with Coverage Policies: Clear and comprehensive documentation ensures compliance with coverage policies.
  • Reduction of Disputes and Audits: Reduces the likelihood of disputes and audits, which can delay payments and impact cash flow.
  • Financial Stability: Addressing documentation errors proactively safeguards revenue streams, enhances operational efficiency, and strengthens financial stability.

Step 2: Engage Radiologists from the Start

Getting radiologists on board early is crucial for the CDI program’s success. Find leaders within the group who are keen on documentation and coding aspects and can influence their peers. These leaders can offer valuable insights during the planning phase, helping to customize the CDI program to fit the radiologists’ workflow without adding excessive burdens. Regular, focused

discussions can help highlight the direct link between thorough documentation and proper reimbursement. Radiologists play a critical role in the documentation process, and their engagement ensures that the program is practical and effective from a clinical perspective.

Ways to Engage Radiologists:

  • Regular Meetings: Schedule regular meetings to discuss progress and address any concerns or challenges faced by the radiologists.
  • Feedback Mechanisms: Set up channels for radiologists to provide feedback on the CDI process, allowing for continuous improvement and adjustments. A formal review with a report of findings has a greater impact than communication to the provider on a case-by-case basis.
  • Incentives: Consider implementing incentive programs for radiologists who consistently meet documentation standards, which can motivate and encourage best practices.

Step 3: Tailor Education to Radiologist Needs

Focused education is vital for the success of a CDI program. Organize training sessions that are concise and frequent, concentrating on common documentation shortcomings that lead to down-coding and denials. Demonstrating the risks of non-compliance, including lost payments, prepayment audits, and potential fines, is also effective. Utilize actual case studies from your group to illustrate how specific improvements in documentation can protect against revenue loss. Training should be practical and relevant, addressing the unique challenges faced by radiologists. Interactive workshops and e-learning modules can be effective ways to engage radiologists and technologists, ensuring they understand the importance of correct documentation and how it affects reimbursement.

Educational Methods:

  • Workshops: Conduct hands-on workshops where radiologists can practice documenting under guidance and receive instant feedback.
  • E-Learning Modules: Develop interactive e-learning modules that radiologists can complete at their own pace.
  • Case Studies: Use real-life examples to highlight the impact of good documentation practices on reimbursement and compliance.
  • Continuous Learning: Offer periodic refresher courses and updates on new regulations or changes in coding practices.

Step 4: Utilize Efficient Documentation Tools

Introduce practical tools that facilitate correct documentation.

  • Cheat Sheets: Creating cheat sheets for common procedures that have specific documentation requirements or that are often down-coded due to missing details can be extremely helpful to the radiologist who may not be familiar with all the specific coding guidelines required for certain procedures such as ultrasounds. These cheat sheets can serve as quick reference guides during the documentation process, ensuring that all necessary information is captured accurately and completely.
  • Technologist Education: Educating technologists on capturing patient symptoms and relevant clinical information can significantly improve the quality of documentation. Often, diagnosis data is captured early on in EMR systems, flowing from scheduling to technologist into the radiology report. By providing technologists with training on the importance of accurate and detailed patient information, the radiologists can receive more complete and useful data, reducing the documentation burden on them and enhancing the overall accuracy of the reports.

Regular Feedback:

Implementing a system for providing radiologists and technologists with regular feedback on their documentation can help find common errors and areas for improvement. For instance, monthly audits of a sample of reports can highlight trends in documentation deficiencies, which can then be addressed through targeted training sessions. Constructive feedback not only helps in correcting mistakes but also reinforces good practices, fostering a culture of continuous learning and quality improvement. Feedback sessions can also include discussions about recent changes in coding guidelines and payer requirements, ensuring that all team members are up to date with current standards.

Step 5: Continuous Monitoring and Adjustment

A CDI program must be adaptable to changing regulations, clinical practices, and technological advancements.

Regular Audits:

Set up regular audits to evaluate the effectiveness of the CDI strategies. Metrics such as rates of down-coding, denial frequencies, and response times to queries can be valuable indicators of the program’s performance. The extent and frequency of audits will vary, based on practice needs. The more reviews performed, over time, the less likely you are to find major problems. Continuous dialogue with the radiology team is essential to refine the program and ensure it meets its goals.

In-House and Outsourced Expertise:

Effective monitoring and adjustment of a CDI program may require a combination of in-house and outsourced expertise.

  • In-House CDI Teams: Responsible for day-to-day documentation reviews, providing immediate feedback to radiologists, and ensuring compliance with current coding guidelines. These teams should regularly collect and analyze data on key metrics such as down-coding rates, denial frequencies, and average response times to coding queries. Advanced analytics tools can help in finding patterns and trends, allowing for more targeted interventions and training.
  • Outsourced CDI Vendors: Provide added support by conducting comprehensive audits and offering an external perspective on documentation practices. They can benchmark a

practice’s performance against industry standards and provide specialized expertise in areas where the in-house team may need added support. Expectations from outsourced teams should include detailed audit reports, actionable recommendations for improvement, and ongoing training and support to address identified issues.

Setting Up an Audit Program:

To scope out and set up an audit program within a practice:

  • Define the Scope and Objectives: Find the key metrics to be monitored, such as documentation completeness, accuracy, and timeliness.
  • Develop a Structured Audit Schedule: Ensure regular reviews (e.g., monthly, or quarterly) to keep track of progress and find any emerging issues.
  • Assign Dedicated Staff: Perform the audits or engage with an external vendor if additional expertise is needed.

Audit Process:

During the audits, randomly select a sample of radiology reports for detailed review. Evaluate these reports against established documentation standards and coding guidelines. Look for common issues such as missing information, incorrect coding, or inconsistencies in documentation. Summarize the findings in a report, highlighting both strengths and areas for improvement. Share the audit results with the radiology team and provide constructive feedback. Use the findings to inform ongoing education and training efforts, focusing on the areas where deficiencies were noted. Regularly revisit the audit program to ensure it remains aligned with the practice’s goals and adapts to any changes in regulations or clinical practices.

Step 6: Recognize Achievements and Cultivate Leadership

Acknowledging the contributions of individuals who excel in implementing CDI practices can motivate the entire group. Public recognition of successes in meetings or through internal communications can reinforce the value of everyone’s efforts. Finding and developing new leaders from these success stories can help sustain and evolve the CDI program. Recognition can take many forms, from certificates and awards to highlighting accomplishments in newsletters or during team meetings. Encouraging a culture of recognition fosters a positive working environment and motivates staff to keep high standards in documentation.

Recognizing Excellence:

  • Certificates and Awards: Distribute certificates and awards to individuals who consistently meet or exceed documentation standards.
  • Internal Communications: Highlight accomplishments in internal newsletters or bulletins.
  • Leadership Development: Name top performers and provide them with opportunities for further leadership development and training.

Conclusion

For radiology groups, implementing a CDI program is a strategic move toward securing proper reimbursement through meticulous documentation. By establishing specific goals, engaging radiologists early, delivering targeted education, incorporating efficient tools, continuously monitoring progress, and celebrating achievements, your group can enhance documentation practices that directly translate into improved financial health.

Laura Manser CPC, CDEO, CIRCC, CPMA, CEMC, RCC, is the Director of Provider Education at PBS Radiology Business Experts. With 24 years of radiology experience, she is a trusted subject matter expert in coding, auditing, and documentation improvement. A dedicated educator, Laura trains coders and physicians to enhance coding accuracy, documentation quality, compliance, and revenue optimization through tailored programs. Holding multiple certifications from AAPC and RCCB, Laura is known for her proactive leadership, strong work ethic, and commitment to excellence in radiology.

May 28, 2024
By: Desiree Overcast, Chief Operations Officer

In today’s digital age, data security is paramount, especially in industries handling sensitive information like healthcare. At PBS Radiology, safeguarding our clients’ data is our top priority. We employ a range of advanced technologies and best practices to ensure the confidentiality, integrity, and availability of patient information. Here’s how we utilize cutting-edge technologies to keep our clients’ information safe:

SOC 2, Type 2 Compliance: PBS Radiology is proud to be SOC 2, Type 2 compliant. SOC (Service Organization Control) is a cybersecurity compliance framework developed by the American Institute of Certified Public Accountants (AICPA). SOC 2 compliance ensures that our internal controls and systems related to security, availability, processing integrity, confidentiality, and privacy of data are handled appropriately. This certification provides our clients with the assurance that their data is managed securely and in compliance with industry standards.

Multi-Factor Authentication (MFA): We enhance the security of our accounts and sensitive information through Multi-Factor Authentication (MFA). MFA requires multiple forms of verification, such as a password and a temporary code sent to a mobile device, to access our systems and applications. This additional layer of security significantly reduces the risk of unauthorized access, even if login credentials are compromised.

Endpoint Detection and Response (EDR): Endpoint Detection and Response (EDR) is a crucial component of our cybersecurity strategy. EDR solutions continuously monitor end-user devices, such as desktops, laptops, and mobile devices, to detect and respond to cyber threats like ransomware and malware. By actively monitoring endpoints, we can quickly identify and mitigate security incidents, minimizing the impact on our operations and protecting our clients’ data.

Security Awareness Training: We recognize that security habits are fundamental to cybersecurity. That’s why we provide annual Security Awareness Training to all our employees. Our training programs educate our team members on best practices for data security, including how to identify and respond to potential threats effectively. An informed team is our most valuable asset in maintaining a secure environment for our clients’ information.

Phishing Tests: Phishing remains one of the most common and effective methods used by cybercriminals to compromise data security. To combat this threat, we conduct regular phishing tests and simulations for our employees. These simulations provide valuable insights into our team’s awareness of phishing threats and help identify areas for improvement. By educating our employees and reinforcing their ability to recognize and avoid phishing attacks, we reduce the risk of data breaches and financial losses.

In conclusion, at PBS Radiology, we are committed to leveraging advanced technologies and best practices to ensure the security of our clients’ information. By staying SOC 2 compliant, implementing MFA, utilizing EDR solutions, providing security awareness training, and conducting phishing tests, we strengthen our defenses against cyber threats and uphold our commitment to data security and privacy. Our proactive approach to cybersecurity enables us to deliver high-quality services while safeguarding our clients’ trust and confidentiality.


Desiree Overcast leads our operational teams and is active in all aspects of client implementation and technology. Desiree came to PBS from a large imaging center where she led IT administration. She has years of experience in operational workflows of multiple radiology practices through her work with PBS. Desiree also brings a keen understanding of RIS/PACS/EMR/HL7 interfaces. Her unique operational perspective combined with this technical expertise delivers unparalleled results for our clients. Desiree brings critical understanding and know-how to maintain, streamline, automate and advance PBS workflows and systems to deliver superior operational and technical fluidity for our clients. 

May 7, 2024
By: Laura Manser, CPC, CDEO, CIRCC, CPMA, CEMC, RCC, Director of Provider Education

We are at an exciting juncture in our company’s history. Recognizing the critical role of clinical documentation in the delivery of high-quality healthcare, we are doubling down on our efforts to expand and enrich our Clinical Documentation Improvement (CDI) program. This initiative is not new to us; it has been a cornerstone of PBS’s commitment to excellence. However, we are now investing more resources and time than ever before to enhance this program. Our goal is to not only maintain but elevate the standards of documentation that facilitate accurate diagnoses that support medical necessity, improve proper reimbursement, and ensure compliance with healthcare regulations.

Given the challenges of the past few years, including Medicare radiology reimbursement reductions, a shortage of radiologists, and the hurdles posed by the flawed MIPS program, all of which have put considerable pressure on the field of radiology, the significance of achieving accurate reimbursement through proper report documentation has never been more critical. These circumstances highlight the crucial importance of our CDI program. Proper documentation stands as a beacon of control and certainty in an uncertain landscape, ensuring that your practice claims the reimbursement that accurately reflects the true value of the services provided.

Our CDI program is more than just a service; it is a value-added partnership. We are committed to working closely with you, our physicians and healthcare providers, to make clinical documentation a seamless part of your workflow.

Designed with our providers at the forefront, this enhanced CDI program aims to support you in navigating the complexities of medical documentation, offering the time, training, and ongoing guidance necessary to refine the documentation process. By enhancing documentation accuracy and completeness, we can reduce administrative burdens to the physicians, thereby enabling you to devote more attention to patient care.

As your Director of Provider Education, I am particularly excited about the opportunities this program presents for collaborative learning and improvement. Teaching and sharing knowledge are not just aspects of my job; they are my passion. Drawing from my previous experience as a coding manager, shaping our medical coding team through effective training and supportive learning environments, has reinforced my belief in the power of education. I am dedicated to extending this educational approach to our provider initiatives.

A few of our commitments to our clients are documentation reviews, quarterly accuracy and documentation audits, monthly feedback on medical necessity and denials, and education on report template optimization. Please don’t hesitate to reach out to me with coding or documentation questions, or to schedule a coding education and documentation review session for your providers.

I look forward to this journey with you, valuing your feedback, insights, and partnership as we aim to position our CDI program as a paragon of excellence in the healthcare industry. Together, let’s pave the way for a future marked by compliance, efficiency, proper reimbursement, and most importantly, exceptional patient care.

Warmest regards,
Laura Manser, CPC, CEMC, CPMA, CIRCC, RCC Director of Provider Education

Laura Manser, CPC, CDEO, CIRCC, CPMA, CEMC, RCC, is the Director of Provider Education at PBS Radiology Business Experts. With 24 years of radiology experience, she is a trusted subject matter expert in coding, auditing, and documentation improvement. A dedicated educator, Laura trains coders and physicians to enhance coding accuracy, documentation quality, compliance, and revenue optimization through tailored programs. Holding multiple certifications from AAPC and RCCB, Laura is known for her proactive leadership, strong work ethic, and commitment to excellence in radiology.

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