1. Obtaining Relevant Radiology Request Information University of Wisconsin Hospital and Clinics University of Wisconsin-Madison, Wisconsin Quality Care demands Quality Information

2. Problem F Lack of accurate, salient clinical information on radiology requests may lead to: »Suboptimal performance/interpretation of exam »Coding and billing inaccuracies »Potential medico-legal implications F Who should be gatekeeper?

3. Vision F Identify need for improvement for benefit of organization F Root causes F Identify solutions F Educate physicians and staff F Involve institution in ongoing compliance

4. Team Members F Quality Improvement Department (Team Leader) F Radiologist - Body Imaging F Laboratory Medicine Physician F Information Systems Physician Director, Emergency Department F Radiology Administrator F Transplant Floor Unit Clerk F Unit Clerk Educational Coordinator F Information Systems Project Leader F Oncology Program Assistant F Management Engineer F Ad Hoc Team Members (Physician Billing Mgr, UWHC Fiscal Mgr)

5. Goal To increase to 90% the number of radiology requisitions with accurate and appropriate salient clinical information.

6. Suboptimal Exams/Interpretations Improvements Would Result In: F Technologists focusing on area of concern F Quality radiologist interpretation F Better communication between referring clinician and radiologist

7. Coding and Billing Inaccuracies F Develop documentation standards for Radiology, Lab, Pharmacy, ECG, etc

8. Potential Medico-Legal Implications F Medicare requirements »Federal Register 42CFR424.10 - 11 F Medical necessity »all procedures (radiology and non-radiology) must have a clinical condition to be a payable service* F Frequency »must be appropriate for clinical condition* (*refer to Section 18.14(a)(2) and 18.35(a)(2) of the Social Security Act)

9. Implications of Medicare Non-Compliance F Over $33K lost/written off in monthly Medicare charges F If reason for exam not substantiated, cannot bill F HCFA audit could result in: –Allegations of Fraud –Fines

10. Root Causes F Clinician verbal/written order interpreted incorrectly F Order transcribed/entered into system incorrectly F Radiology handling of information

11. Solutions F Developed an Acronym (CYA) to Assist Clinicians in Remembering Required Information »C Current diagnosis »Y Why you want the exam »A Already known history relevant to the study being requested

12. Solutions (cont’d) F Educated clinicians, radiologists and staff F Visual reminders F Incentives to house staff for providing adequate information F Mandated correct pager numbers be provided

13. General Ordering Rules F DO NOT give the following as the ONLY information »“R/O” (alone) »“Possible” »“Probable” »“Suspected” »“Pre-Op” »“Screening” F DO list specific clinical dx, signs, sx, or patient complaints »“RLQ pain” »“malignant renal hypertensive disease” »“SOB/cough, R/O pneumonia” »“Accident--give type”

14. Benefits of “CYA” Ordering F Documents “medical necessity” of ordered test F Quality patient care F Good customer service F Prevents unnecessary phone calls F Correct coding and billing benefits entire organization’s bottom line

15. Implementation F Piloted program on Hematology/Oncology Inpatient unit »Educated clinicians and staff »Developed a team logo “Quality Care Demands Quality Information” Quality Care demands Quality Information

16. Implementation (cont’d) F Target inpatient implementation (2 units) completed July, 1997 –Pre-implementation compliance: 52% –At peak of our efforts: 67% F House-wide ambulatory clinic implementation initiated February, 1998

17. Internal Medicine, Surgery and Oncology Clinic Implementation

18. Implementation (cont’d) F Gave ‘report card’ of what was needed to bring in compliance F Re-checks and follow-up done after implementation

19. Implementation, Phase B F Compliance fell, implemented Phase B F “No Data, No Study” F Project employees hired F Notified clinicians that lack of compliance would result in refusal to study effective July 1, 1999

20. Lessons Learned F Identify specific problems F Team should have physician/staff make up F Identify gatekeeper early in process F Obtain buy-in from department chairs F Identify areas of non-compliance, focus education F Educate in large setting and one-on-one

21. Lessons Learned (cont’d) F Provide specific feedback F Pilot an “easy” area F Present updates and findings to hospital administration, Compliance Committee F Be prepared to take hard approach (“no data, no study”) F Orient new medical staff

22. How Are We Doing Now? F Two-years post education and implementation F Compliance Rate = 98% (ambulatory procedures only)

23. University of Wisconsin-Madison Margaret L. Birrenkott, MBA Administrator & Director, Business Services Department of Radiology Education Team Members: Kris Leahy-Gross, RN Fred Kelcz, M.D. Carol Hassemer