There is no universally agreed upon definition of a “good” radiological report. While reports can vary in style and format, the objective to communicate results to an ordering provider remains constant. Although a radiology report’s primary function is to convey findings, they are now tied to several other aspects of the healthcare landscape. The content of a radiology report is directly related to how a claim gets coded and certain verbiage, or lack of, can impact compliance and liability. Many in the industry have turned to using tools, like templates or macros, to help streamline the reporting process and generate complete and consistent reports. However, these solutions should always be used with certain considerations in mind.
Be wary that terms are often used interchangeably when discussing the use of any structured report (or standardized reports), templates, and macros and these terms can mean different things depending on context. Structured reports can refer to the use of a standardized reporting format, such as using a set of standard headings like “clinical history”, “comparison”, “impression. Structured reports can also refer to downloadable templates for dictation software that prompt data capture and insert sets of verbiage based on a radiologist’s input. For ADVOCATE, we consider a template to be a sample of a full report or an example of what the end product should look like. A macro is a programmable pattern which translates a certain input, like a key stroke or dictated phrase, to a preset output. Macros can also be referred to as templates as they produce a set of standard text into a report.
Using these tools can provide many benefits to the dictating physician, ordering provider and patient. Having a process to incorporate standardization by using a structured report, template, or macro can increase efficiency for the radiologist while creating consistency in verbiage. This can be critical for physicians that participate in MIPS (Merit Based Incentive Program) where quality measures often rely on the inclusion of specific language in all applicable reports to receive a high score. Ordering providers can benefit by receiving reports that are complete with improved clarity, quality, and consistent terminology. Standardized language and report completeness support the flow of communication from provider to patient and enhances patient outcomes.
Although the benefits of using tools to aid in report creation are numerous, so are the cautions and considerations to make when incorporating them into a workflow. Default language should never be used to create an entire report. Reports must be patient specific and tailored to the encounter. The use of ‘cloned notes’ is highly cautioned against by CMS. Unlike a macro that inputs canned language based on key input, ‘cloned notes’ is the act of copying previously recorded information within an EHR from one medical record to another. Obvious copying and pasting can make one vulnerable to an audit, especially if ‘cloning notes’ for evaluation and management encounters. CMS has also cautioned against using templates that limit the options for collecting information or prevent a user from inputting patient specific information. Additionally, it is important that any sort of structured report, template, or macro be maintained with the most up to date clinical language.
ADVOCATE recognizes the importance and benefits of adopting standardization tools within the reporting workflow. Due to the nature of specific CPT documentation requirements, adoption of consistent patterns of dictation to include key elements of an exam have proven to demonstrate the most effective communication that fulfills both clinical and CPT criteria. Through our unmatched experience in radiology coding, we have identified many documentation risk areas that can create issues for radiology groups. As a result, in addition to regular physician education, we have created our own template library which is readily available to our clients. This library contains templates for over 50 types of studies, as well as radiology’s commonly reported MIPS measures. There are times when the appropriate language required for a study from a CPT perspective may not seem to be the most relevant clinically and sometimes terminology variances can cause headaches. However, it is important to keep in mind that a coder will assign an appropriate code based off AMA (American Medical Association) CPT language in order to code a claim and cannot use clinical judgement.
As a reminder, for ADVOCATE, our templates show an example of what a finished report should look like, assuming the exam requirements are met for a particular study and is not a form to generate a report. Keep in mind that an entire report should never be made up of entirely default language. ADVOCATE aims to support our clients and can review the macro language that appears on a report and provide recommendations. Unfortunately, we are unable to control if and how macros are used by individual providers or facilities. In any case, ADVOCATE is available as a valuable resource for documentation requirements for our clients and remains committed to providing the best feedback and education available.
Director of Coding Education
Manager, Regulatory Affairs