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 reports from 37 practices were used to identify and analyze abdominal ultrasound reports. Using standard Current Procedural Terminology (R) (CPT (R)) criteria, examinations were categorized as complete (all 8 required elements documented) or limited (<8 elements). Assuming incomplete documentation, examinations were categorized as very likely, likely, or possibly complete depending on whether a minimum of 7, 6, or 5 elements were reported. Frequency and financial impact were assessed using all 3 models, and presumed documentation deficiencies were characterized. Results: Of 336,062 abdominal ultrasound reports by 1,136 radiologists, 252,478 (75.1%) documented all 8 elements for CPT coding as complete examinations, 25,925 (7.7%) documented 7 elements, 20,559 (5.6%) documented 6 elements, 17,521 (4.8%) documented 5 elements, and 49,579 (13.5%) documented <= 4 elements. For very likely, likely, and possibly complete examination models, deficiencies were present in 9.3%, 15.5%, and 20.2% of cases, resulting in 2.5%, 4.2%, and 5.5% decreases in legitimate professional payments. The spleen (41.2%) was the most frequent element neglected. Of 106,168 examinations titled complete, only 92,824 (87.4%) fulfilled complete CPT criteria. In 221,887 (60.6%), examination titles were clearly erroneous or too ambiguous for code assignment. Documentation deficiencies were less frequent for high-volume radiologists (P < .0001). Conclusions: Incomplete physician documentation in abdominal ultrasound reports is common (9.3%-20.2% of cases) and results in 2.5% to 5.5% in lost professional income. Structured reporting may improve documentation and mitigate lost revenue.