From small practices to large health systems, optimizing reimbursements through accurate clinical documentation is essential for financial health, sustainability, and growth. It also plays a critical role in maintaining compliance with regulations and providing high-quality patient care. 

Learn how to optimize reimbursements from your exams and ensure the financial health and sustainability of your organization by evaluating these four key areas related to ultrasound documentation. 

1. Accuracy of Documentation  

Prioritize comprehensive, clear, and precise documentation.  

Accurate and comprehensive documentation of ultrasound procedures is essential for optimizing your billing practices. By ensuring precise documentation, you minimize the risk of claim denials and audits.  

It’s crucial each ultrasound report clearly describes and outlines the type of examination, findings, measurements, interpretations, and any associated diagnoses. Inadequate or ambiguous documentation can result in coding errors, claim denials, and delays in reimbursement, impacting the overall financial health of your organization.  

Accurate documentation also lays the foundation for effective charge capture by ensuring that all the services performed during the ultrasound procedure are clearly recorded.  

2. Effective Charge Capture and Reconciliation  

Ensure all services rendered are billed appropriately with timely and accurate charge reconciliation.  

Effective charge capture involves accurately recording and reconciling all billable ultrasound services and includes not only the main ultrasound procedure, but also additional services that were completed during the examination.  

Failing to capture charges appropriately can result in lost revenue, billing errors, claim denials, and compliance issues. To ensure effective charge capture, healthcare organizations should implement processes, technologies, and quality assurance measures to minimize errors.  

Timely and accurate charge capture will maximize efficiency by ensuring that all billable services are properly recorded and billed. Additionally, streamlined workflows and reduced administrative burden will free up resources to focus on other priorities.  

3. Compliance of Coding and Billing  

Ensure compliance with coding guidelines and regulations.  

Proper coding and billing practices prevent underbilling and overbilling, which could lead to significant losses, legal issues, and penalties. Compliance with coding guidelines is also crucial for maintaining trust with patients and payers.  

Ultrasound procedures have specific Current Procedural Terminology (CPT) codes that must be assigned correctly based on the documentation. Compliance with relevant coding and billing rules, such as National Correct Coding Initiative (NCCI) edits and local coverage determinations (LCDs), helps prevent claim denials and audits.  

Properly coded and billed claims also provide reliable data for financial analysis. This data is invaluable in identifying revenue trends, potential areas for improvement, and strategic decision-making opportunities to enhance your organization’s financial performance.  

  

4. Ongoing Staff Education and Training  

Improve departmental efficiency with ongoing training and education. 

Providing ongoing training and education to staff is crucial for maintaining a well-informed and efficient department. They should be familiar with coding and billing guidelines, documentation requirements, insurance policies, and any updates or changes in regulations.   

Also ensure that staff have access to reliable support and receive thorough onboarding and training for the technology you leverage. Properly trained staff are more likely to accurately capture charges, reduce errors, and contribute to departmental efficiency within a more financially efficient department.  

By addressing these areas and implementing technology to help automate coding and correct errors, ultrasound departments can enhance their processes to optimize reimbursements, ensure financial sustainability, and improve patient care.  

As medical imaging has advanced, a variety of electronic systems and their various technology-based components, such as image archiving systems, ultrasound machines, ultrasound reporting systems and billing systems, have evolved within ultrasound network architectures.  

Each of these components communicate through a variety of interfaces, typically created by different vendor companies with limited collaboration, who focus on their individual components rather than seamless network connectivity. 

“Because this customization requires institutional willingness and resources, most ultrasound networks do not seamlessly provide the clinical information necessary to improve clinical care efficiency and quality.” (SMFM) 

To help facilitate better collaboration, clinicians, maternal-fetal medicine sub-specialists and network vendors, including AS Software, were brought together by the Society for Maternal-Fetal Medicine Clinical Informatics Committee to establish best practices and a better understanding of obstetrical ultrasound network architectures, now published by the American Journal of Obstetrics and Gynecology in a special statement. 

Here is a summary of the best practices collaboratively provided for seamless prenatal ultrasound network connectivity: 

1. Use a generalized approach to order design for more clinical flexibility 

There are unique challenges to order design for prenatal ultrasounds due to the frequent need for mid-study adjustments in obstetrics.  

The two most common approaches are to use multiple individual procedure-based orders, or to use a few generalized orders with embedded procedural options. 

While each approach to order design has its limitations and may depend on unique workflows, the ideal approach is typically a generalized one. In this approach, a handful of high-level orders with procedural specificity selected within the body of each order are used. A conditional request can also be embedded based on the study results, and even extend to consultative services. 

This will give greater clinical flexibility, so clinicians can adjust as needed without requiring new orders. 

2. Establish a straightforward data standard to improve communication 

Although there have been standards for formats of communication, like HL7 and DICOM, the content and clinical format of obstetrical data hasn’t had a standard for how it’s transmitted across systems.  

Depending on the individual vendors and design of each component, there are many variations of how data transfer and format is customized through interfaces — leading to varying capacities and complicated translations of each data point that make it difficult for practitioners to effectively leverage data.  

By standardizing ultrasound data transfer and improving consistency, clinicians will have increased analytical capabilities and access to discrete obstetrical data, and communication will be improved between vendors.  This straightforward integration is also less costly for IT professionals. 

3. Optimize billing with search functionality and integrations 

ICD-10-CM and CPT are the standards for coding in ultrasound workflows, but clinics vary on how they send this information and some use paper order sets.  

All requested procedures, associated diagnoses, and indications are best sent via HL7 order entry message to an ultrasound reporting system (URS). The URS should have search functionality for CPT and ICD-10-CM codes, and automatically populate necessary sections of study reports. 

All billing and coding systems should also seamlessly integrate with health information systems; and study procedure and diagnosis codes should automatically populate for final review. 

As imaging technology continues to advance, so will the technology-based components supporting it. These best practices will help both providers and vendors ensure their network  and its interfaces are structured effectively for better communication and more standardized data transfers, relieving burdens placed on healthcare systems. 

To read more about best practices for ultrasound network connectivity, read the entire special statement in the American Journal of Obstetrics and Gynecology or download a PDF on the Society of Maternal-Fetal Medicine site. 

To help better understand your organization’s electronic systems and how they could communicate more effectively, schedule a consultation here.