Physician Documentation Deficiencies in Abdominal Ultrasound Reports: Frequency, Characteristics, and Financial Impact

Purpose The aim of this study was to assess the frequency, characteristics, and financial impact of physician documentation deficiencies in abdominal ultrasound reports. Methods Using a multi-institutional coding and billing database and natural language processing software, 12,699,502 radiology rep...

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Veröffentlicht in:	Journal of the American College of Radiology 2012-06, Vol.9 (6), p.403-408
Hauptverfasser:	Duszak, Richard, MD, Nossal, Michael, MA, Schofield, Lyle, BS, Picus, Daniel, MD
Format:	Artikel
Sprache:	eng
Schlagworte:	Abdomen - diagnostic imaging Abdominal ultrasound CPT coding Diagnostic Errors - economics Diagnostic Errors - statistics & numerical data Documentation - economics Documentation - statistics & numerical data Humans natural language processing physician documentation deficiencies Physicians - economics Physicians - statistics & numerical data radiologist reporting Radiology Sensitivity and Specificity Ultrasonography - economics Ultrasonography - statistics & numerical data United States
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Beschreibung
Zusammenfassung:	Purpose The aim of this study was to assess the frequency, characteristics, and financial impact of physician documentation deficiencies in abdominal ultrasound reports. Methods Using a multi-institutional coding and billing database and natural language processing software, 12,699,502 radiology reports from 37 practices were used to identify and analyze abdominal ultrasound reports. Using standard Current Procedural Terminology® (CPT® ) criteria, examinations were categorized as complete (all 8 required elements documented) or limited (
ISSN:	1546-1440 1558-349X
DOI:	10.1016/j.jacr.2012.01.006