CODING CORNER: Dictation Standards

Posted 10:15 AM, May 21, 2007, by jaruiz

By Darryl Costales
(Image courtesy of Mark Riesenberger)

Did you know that radiology dictation plays an important role in being reimbursed appropriately? Of course, patient care is our primary focus when we talk about the contents of a dictation. But we also need to be aware that if a report does not support the charge, then payment could be delayed or denied. Internal (and external) auditors could require us to refund any payments if the report does not support the charges.

Question: Do you know what the American College of Radiology (ACR) recommendations are for a standard radiology report dictation?

Answer: Effective communication is a critical component of diagnostic imaging. Quality patient care can only be achieved when study results are conveyed in a timely fashion to those ultimately responsible for treatment decisions. An effective method of communication should: (a) be tailored to satisfy the need for timeliness; (b) support the role of a diagnostic imager as a physician communication; and (c) minimize the risk of communication error.

The following are the suggested components of a dictation report from the ACR web site:

1. Demographics
a. The facility or location where the study was performed.

b. Name of the patient and another identifier (MR#).

c. Name(s) of referring physicians or other healthcare provider. If the patient is self referred, that should be stated.

d. Name or type of exam.

e. Date of exam.

f. Time of the exam, if relevant (e.g., for patients who are likely to have more than one type of a given exam per day).

g. Inclusion of the following additional items is encouraged.
--Date of dictation
--Date and time of transcription
--Birth date or age
--Gender

2. Relevant clinical information and ICD-9 code, if available

3. Body of report
a. Procedures and materials. The report should always include a description of the studies and/or procedures performed and any contrast media (including concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere. Any known significant patient reaction or complication should be recorded.

b. Findings. The report should use appropriate anatomic, pathologic, and radiologic terminology to describe findings.

c. Potential limitations. The report should, when appropriate, identify factors that may compromise the sensitivity and specificity of the examination.

d. Clinical issues. The report should address and answer any specific clinical questions. If there are factors that prevent the answering of a clinical question, this should be reported.

e. Comparison studies and reports. Comparison with relevant examinations and reports should be part of the radiologic consultation and reported when appropriate and available.

4. Impression
a. Unless the report is brief, each report should contain an "impression" section.

b. A precise diagnosis should be given when possible.

c. A differential diagnosis should be rendered when appropriate.

d. Follow-up or additional diagnostic studies should be suggested when appropriate.

e. Any significant patient reactions should be reported.

5. Standardized computer-generated template reports. Standardized computer-generated template reports that satisfy the above criteria are considered to conform to these guidelines.