What Really Needs to be in That Cath Procedure Report? Finally…a Statement on Structured Reporting

Marsha is Director at Corazon, Inc., offering consulting, recruitment, interim management, and IT solutions for hospitals and practices in the heart, vascular, neuro, and orthopedics specialties. To learn more, call (412) 364-8200 or visit www.corazoninc.com. To reach the author, email mknapik@corazoninc.com.

As consultants engaged to assist organizations with the implementation of new cardiac cath labs, coding and billing assessment and optimization, or quality reviews, Corazon frequently identifies physician procedural documentation as an area in need of attention. Often this documentation can be incomplete, inconsistent, or in a format that causes difficulty with understanding pertinent details associated with the procedure and/or the patient clinical response and outcome.  The recent announcement of a (soon-to-be published) 2014 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) Health Policy Statement on Structured Reporting for the Cardiac Catheterization Laboratory¹ (hereafter referred to as  “HPS on Structured Reporting”) provides clarity as to the key components of procedural reporting, and also provides template examples that can be used to provide this consistency. We believe that following the HPS on Structured Reporting will assist programs from both a quality and risk perspective.

Federal regulations, along with The Joint Commission, have long required that the following items be included in a procedure report:

• Indications;
• Procedure performed;
• Results or outcome;
• Complications;
• Recommendations;
• Logistical, operator, and administrative information.

Although the recommended items for inclusion in a comprehensive report appear quite clear, we see wide variation in not only report formats, but in content as well. Many times, rather than providing much-needed information, reports instead create confusion as to the final procedure and may, in fact, contradict information contained in the cardiac catheterization procedure documentation (log). This inconsistency and lack of clarity certainly does not serve the patient well, and can present a medical/ legal risk to both the provider and to the organization. Inconsistent documentation practices also contribute to coding and billing errors, which could negatively impact reimbursement.

Due to the clinical, operational, and financial consequences of inaccurate reporting, Corazon recommends a template or structured approach to procedure reporting that will also adhere to the forthcoming HPS on Structured Reporting. With the appropriate focus and leadership, many organizations are able to implement and adhere to a structured approach. Other organizations, however, struggle to not only develop the necessary templates and tools, but also to gain physician buy-in and compliance in the use of the recommended format.  

Rationale for a structured approach

The HPS on Structured Reporting is “intended to provide a general model for structured reporting” and through its endorsement of the policy, collectively, the ACC, AHA, and SCAI “calls for its uniform adoption.”² 

When performing a procedure, the final report provides key information that is used in multiple ways following the procedure. The data is used not only to assess that the procedure was appropriately indicated, but provides technical detail, patient procedure response and outcomes, and recommendations. The report is not only an ongoing patient care record and is considered a medical/legal document, but is also used for:

• Coding and billing;
• Inventory management;
• Outcomes assessment and quality reporting; and 
• As a data source for registry entry.

Given the many uses for the report, its accuracy is extremely important to many facets of the cath lab, and to the cardiac program overall. Thus, developing strategies now for future adherence to the HPS should be a top priority nationwide.  

The ACC/AHA/SCAI HPS on Structured Reporting indicates that structured reporting is to be “considered one component of the overall quality improvement imperative for cardiovascular care.”¹ Indeed, having a standardized approach to the report removes any confusion as to where to find key documentation elements for any of the above-listed purposes. The key elements will appear in every report in the same location every time. Variations in documentation should be eliminated and theoretically, no critical data elements will be missing. 

Report structure/components

At first glance, the report structure and included components can be daunting. However, a closer review reveals that most of these elements are typically already included by operators who currently provide a complete procedure report. For those operators who often have delayed reporting, the advantages will quickly become evident when finalizing the report at the completion of the procedure or very soon after, when all of the data is readily at hand.  

The report structure provides consistency in both format and included data elements. Over time, accessing a procedure report and knowing where to go in that report for particular piece of information will become easier, as data should appear in the same order or location every time, regardless of the operator, the facility, or the reporting system (vendor).  

For all procedure reports, the policy identifies three sections. The first section is a one-page procedure summary with all key elements provided. The HPS on Structured Reporting identifies this as an executive summary that any clinician can access for a quick, concise summary of what was done with respect to a particular patient. The second section of the report includes any hemodynamics, graphics, and images embedded to whatever degree possible by the imaging/information technology systems in use. The third and final section is a very detailed narrative of the procedure that includes content targeted for regulatory compliance, quality monitoring, appropriate use, and billing.  A large portion of the content of the third section is derived from the procedure documentation completed by the cath lab staff. Thus, this documentation needs to be readily accessible to the physician at case completion for timely final report generation. A brief content outline of the three sections of a cardiac catheterization procedure is provided in Table 1. The HPS on Structured Reporting style guide, with a full description, can be accessed as a pdf download at https://jaccjacc.cardiosource.com/DataSupp/2014_Cathlab_HPS_CathReportStyleGuide.pdf.  The HPS on Structured Reporting provides template detail for other invasive procedures as well, including:

• Cardiac catheterization (right, left combined and coronary interventions);
• Peripheral vascular procedures;
• Cerebrovascular procedures;
• Transcatheter aortic valve replacement (TAVR);
• Congenital and structural heart catheterization; and
• Combination procedures. 

Implementing the approach

Once consensus is achieved with respect to the required components, ensuring compliance with the recommended process is the next step. This issue will take some time and effort, not only for hospitals and physicians, but for vendors as well. Most current cath lab documentation systems have some reporting templates (often a system software option rather than a part of the baseline system), which may not easily fit this newly recommended format. Also, some imaging systems do not easily integrate with documentation systems to allow images to be placed into the report. For those hospitals that do not have or perhaps do not use the physician reporting software available with their hemodynamic system, a dictation process may work for procedure reporting. In any case, it is imperative that hospital medical records departments (for the dictation and transcription aspects) and the vendors (for the reporting software for hemodynamic systems) begin to develop templates that follow the health policy statement. Although there is no timeline for this practice statement to become a guideline or “recommendation,” it is inevitably on the horizon. This documentation change will not occur overnight, and will no doubt come at a cost to organizations — either in time for internal report template development or for the purchase of upgraded software with new report templates for existing systems.  

Once a template is in place for the reporting (whether via the software or via a dictation process), maximum effort to educate physicians as to the required elements will be necessary, as will training for coders, cath lab staff, data registry personnel, and any other clinicians who frequently access and/or use the invasive lab reports. Physician adherence to the report format will require an auditing process as well as some type of penalty system if compliance is not consistent. Medical directors and department chairs will be vital in championing compliance with the new guidelines. The transition to a more complete and formatted report will not be without some resistance, but advance preparation and communication to the team will do much to ease the transition and create buy-in from the outset based on the eventual benefits of the change. 

Benefits of structured reporting

Indeed, the benefits of structured reporting will far outweigh the time and energy expended to overcome the challenges of getting the necessary process in place. For coding and billing purposes, clear documentation that can translate into precise and expedited coding will result, which will thereby decrease charge lag and decrease denials while improving reimbursement turnaround times. Data registry personnel can also quickly access key elements for data entry, eliminating the need to sort through several chart documents or notes to find documentation. A report format that causes the physician to review the staff procedure documentation also ensures that any concerns regarding  the staff procedure documentation can be addressed before the final report is completed, thus eliminating documentation that is not consistent between the procedure notes and the final report, which is critical from a medical/legal risk perspective.

While Corazon recognizes there is much to be done for full acceptance and implementation of structured reporting for invasive laboratory procedures, the HPS on Structured Reporting is a good initial step that provides clear rationale and guidance as to report format and content. Next steps include the engagement of physicians, vendors, and hospitals to continue to move this initiative forward. We believe that those who embrace the HPS on Structured Reporting early on and work to meet the proposed report structure will be best positioned when the statement becomes a recommendation, and will be ahead of the game in regards to coding, billing, and regulatory compliance. 

References

1. Sanborn TA, Tcheng JE, Anderson H, et al. ACC/AHA/SCAI 2014 Health Policy Statement on Structured Reporting for the Cardiac Catheterization Laboratory: A Report of the American College of Cardiology Clinical Quality Committee. J Am Coll Cardiol. 2014;63(23):2591-2623. doi:10.1016/j.jacc.2014.03.020.
2. Nallamothu BK. Journal Scan Summary: ACC/AHA/SCAI 2014 Health Policy Statement on Structured Reporting for the Cardiac Catheterization Laboratory, American College of Cardiology, CardioSource, March 28, 2014. Available online at https://www.cardiosource.org/Science-And-Quality/Journal-Scan/2014/03/ACC-AHA-SCAI-2014-Health-Policy-Statement-on-Structured-Reporting.aspx. Accessed July 11, 2014.