Ideas for Hospitals, Centers, and Practices

New & Noteworthy: Vitrea Pediatric Cardiac Application

Toshiba manufactures a child-friendly Aquilion ONE CT scanner.

Minneapolis-based Vital Images Inc has released its Vitrea Enterprise Suite 1.3, with an enhanced set of workflow tools for pediatric cardiac imaging. In the past, advanced visualization software designed for adults has been used to analyze children, but children are not mini-adults.

“Children have much faster heart rates than adults and are more sensitive to radiation. In addition, they often require sedation to stay still for an exam,” said Bruce Greenberg, MD, with Arkansas Children’s Hospital and a professor of pediatric imaging at the University of Arkansas for Medical Sciences, both in Little Rock. This presents some special challenges with imaging pediatric cardiovascular systems. “You have to balance those aspects against dose,” Greenberg said.

Vitrea is designed to help maximize quality while minimizing dose. New applications include cardiac multi-chamber analysis, which automates atrial and ventricular chamber analysis and leverages low-dose CT scanning protocols; enhanced cardiac structural analysis tools (Vessel Prove and Vessel Walk) to provide easy navigation through anatomy; and additional workflow features that streamline reads, case reviews, and collaboration, such as a new edge-detecting contouring tool, single-click volume segmentation, and improved report access.

The tool was designed in collaboration with long-time strategic partner Toshiba America Medical Systems Inc, Tustin, Calif, and Arkansas Children’s Hospital, which utilizes the Aquilion ONE CT scanner. “If you can get rid of noise, you can reduce dose or keep dose the same and get a sharper picture, and that’s a big part of what’s happening with some of the postprocessing techniques,” Greenberg said.

The Vitrea software uses sophisticated algorithms to remove noise and create better images with less information. Greenberg attributes the capability to advanced computing power. “As we see advances in computers, the ability to run certain software programs has become faster and more practical. In the past, you may have been able to do a certain type of reconstruction, but if it took 6 or 8 hours, that wasn’t very practical. If you could do the same type of thing in 6 or 7 minutes, now it becomes more clinically useful,” Greenberg said.

Combined with other techniques, dose can be significantly reduced. Greenberg will also reduce exposure by limiting it to the specific anatomy (“If they’re only interested in the aortic arch or the branch pulmonary artery, then you probably don’t need to gate the study, which will reduce the dose,” Greenberg said) or using other modalities to fill in information (“Maybe they see enough information with other image modalities, like echocardiography, and we can get by imaging a smaller portion of the chest,” said Greenberg).

The end result is a win for everyone, according to Greenberg, but particularly patients. “We should be able to make better diagnoses using less radiation and that should lead to improved care. I think that moving into the future, we’re going to see almost all of the techniques developing as low-dose techniques,” Greenberg said. That’s new and noteworthy.

—Renee Diiulio

How to Avoid Three Common Billing and Coding Pitfalls

Billing and coding for radiology practices and imaging centers can fall into a rut, and cost the practice a significant sum. These two areas are usually not overlooked, but errors can creep in, and those that affect 5% of collections can cost a typical practice a quarter of a million dollars. And 5% is conservative: error rates can be 10% or higher. Plus, errors can lead to other risks, including delayed reimbursement, increased days in A/R, decreased patient satisfaction, compliance violations, audits, and fines.

Eligibility DenialsOne of the top billing errors is eligibility, which can represent at least 35% to 40% of denials, even in well-run groups. For hospital-based groups, it is very productive for the radiology chair (supported by the billing company client manager or internal expert) to meet with the director of access and other members of the hospital administration and share eligibility denial data. Often, a small improvement in the hospital’s process translates to big benefits for the radiology practice.

Imaging centers have much more direct control over the front-end process and can, therefore, significantly reduce eligibility errors. Best practice recommendations include doing an online eligibility check at the time the procedure is scheduled, particularly for MR, CT, and PET. Even better, add a confirming eligibility check to your front desk procedures when the patient presents.

Physician Referral ErrorsOften, a radiologist will complete a study that is later denied by a commercial payor because what is billed is not the same as what was ordered by the referring physician. For example, an imaging center order and precertification may call for an MRI without contrast. But the practice or the radiologist may have published protocols to do both with and without contrast. If both are billed, it is quite likely that the payor will deny the claim since it doesn’t match the referral.

Also, remember that Medicare is different because it doesn’t require a formal precertification. However, it does require an order, and has specific rules regarding which diagnostic tests are covered. Imaging centers should request a written order from the referring physician, keep it on file, and insist that the referring physician document the request in the patient’s record. The center can then use almost identical referral procedures for patients with Medicare and commercial insurance.

Hospital-based groups may feel that referral errors don’t apply to them. However, commercial payors in some states do require precertification, at least for selected studies. The solution is to create consistent procedures for both Medicare and commercial payors similar to those used by imaging centers.

Dictation MistakesRadiology practices know it is crucial to use correct procedure codes and modifiers to ensure insurers’ acceptance of their claims and proper reimbursement. However, accurate coding depends entirely on accurate documentation, which starts with accurate dictation.

One common dictation mistake is a discrepancy between the header and the body of a report. Examples include: a header listing, “MRI of the head with contrast,” but the report reading, “with and without”; the amount of gadolinium used and amount discarded is missing from the report for an MRI or MRA; the amount of Optiray used and amount discarded and/or the strength of the Optiray (320 vs 350, etc) is missing from the CT report; or the header says one view chest x-ray and the report says two views.

The solution to dictation mistakes is leadership and education. Practice leadership and radiology chairs need to stress the importance of accurate reports. The ACR Practice Guideline for Communication of Diagnostic Imaging Findings can be very useful. A reminder about CMS guidelines can also be helpful.* Practices can ask their coding and billing organization for error rates by physician to highlight those doing well and those who are in need of some improvement. Coders should also be providing formal suggestions and feedback, typically on a quarterly basis.

Dictation will become even more important with the transition to ICD-10, which will replace ICD-9 with a much larger code set. The American Association of Professional Coders recommends radiologists begin training now to effectively implement ICD-10 on time. The organization has developed a training curriculum broken down by year (2009-2013) to help radiologists make the transition to ICD-10.

As you implement these practices, track and analyze results weekly or monthly. You should begin to see reductions in error rates, denials, and billing staff costs. Plus you can be assured of improved compliance and reduced audit risk.

—Bill Gilbert

Bill Gilbert is vice president of marketing, AdvantEdge Healthcare Solutions ( Also contributing to this article were AHS radiology experts: Jeanne Gilreath, CHBME, New Jersey; Kim Girard, CPC, Maine; Lisa Norman, CPC, Illinois; Sharon Virginia, CPC, New York; and William Wheeler, Illinois.

*National Government Services, the Medicare Administrative Contractor (MAC) for New York, Connecticut, Indiana, and Kentucky, states that “the medical record must include a formal written report describing all the views completed. The formal written report must include the reason for the test, a description of the test, the interpretation and results of the test, and the name of the physician to whom the report is being sent.”

New Digital to Analog Converter Delivers Crystal Clarity

Sometimes it’s the little things that make the biggest difference. And Analog Devices Inc (ADI) knows how much the little things can count. It has built its business on building medical components that, though never seen by radiologists or patients, meet their needs for accurate, efficient scans. While it might not be obvious that one of its digital converters is inside an MRI, the images tell the tale.

The AD5791 from Analog Devices promises to improve the next generation of MRI machines.

For instance, the company’s new 4 mm by 6.5 mm AD5791 high-accuracy 20-bit digital-to-analog converter (DAC) scheduled to arrive this month will allow original equipment manufacturers (OEMs) to deliver state-of-the-art MRI imaging systems with 1 part per million (ppm) resolution and accuracy. “You will get images that are clear, crisp, and high contrast,” said Brendan Cronin, marketing manager for ADI. “The AD5791 also reduces the ghosting effect, boosts up time, and limits the number of retakes.”

Because the AD5791 limits image artifacts and has a faster refresh rate, it will result in fewer retakes, saving time and money for busy radiology practices, according to Cronin, so “you don’t build up patients in the waiting room.”

The AD5791 uses a three-wire serial interface, operating at clock rates up to 50 MHz. The 20-bit AD5791 offers a relative accuracy specification of ?1 LSB max, and operation is guaranteed monotonic with a ?1 LSB DNL max specification. The component delivers 0.025 ppm low frequency noise and features 0.05 ppm/C output drift. The output can be configured for standard unipolar (+5 V, +10 V) or bipolar (?5 V, ?10 V) output ranges.

According to the company, the AD5791 has four times better accuracy and resolution than other DACs. Drift is three times less, and noise is 30% less than with other vendors.

From a workflow perspective, the AD5791 makes for a more efficient radiology practice with less need to take an MRI system offline for system calibration cycles. The design also reduces the necessity for complex calibration algorithms, lowering engineering and system maintenance costs, an important factor in today’s health care environment where frequent maintenance can seriously compromise the ability of an imaging center to efficiently image patients.

From a diagnostic perspective, the 1 ppm clarity makes the AD5791 an asset in spotting disease—such as breast cancer—in its earliest stages in the smallest anatomical structures, giving a wider array of treatment options and a better likelihood that clinical outcomes will be optimal.

The biggest benefit of the AD5791 will undoubtedly be seen during the development stage. OEMs are under pressure to deliver high-performing systems, in a timely manner, at an affordable price point. The single-component AD5791 takes some of this pressure off by having a vendor-neutral product that requires less additional engineering, thus lowering price. The component itself is inexpensive, having a $38/1,000 price tag. The small, single component device also helps keep systems’ footprints small, another demand by the health care enterprise as a whole. ADI offers a full complement of support tools for OEMs, including an evaluation kit with PC software for real-time analysis; reference design board with schematics, layout, and code; and application support.

The AD5791 has been engineered to be appropriate for 1.5T to 3.0T MRI systems. But ADI was looking ahead when it developed it. Cronin noted that it has been “future proofed” and will be appropriate for machines up to 11.0T.

MRI digital-to-analog components is only one facet of ADI’s business. It has a multimodality approach, including CT and ultrasound in its portfolio of components.

—C.A. Wolski

Big Benefits with an Open-Bore MR System

When planning a new MR department, there are numerous factors to consider before deciding on the MRIs to purchase. Overlake Hospital Medical Center in Bellevue, Wash, recently made the decision to go with Toshiba’s Vantage TitanTM ultra-short, open-bore MR system. The reasons behind their decision and the benefits of open-bore technology are easy to understand.

When the 337-bed, nonprofit regional medical center servicing the Puget Sound region was shopping for a 1.5T MRI system, patient comfort ranked high on their list. Toshiba’s Vantage Titan’s larger diameter bore provides patients with a greater feeling of openness, reducing claustrophobia. “We chose the large bore for patient comfort primarily. We don’t like to sedate our patients. In fact, I don’t think that we have sedated anybody so far,” said Brenda Rinehart, director of medical imaging at Overlake Hospital.

She explained that its sense of openness also comes from the fact that patients can see out the front and out the back and that for certain procedures they are able to put people in feet first.

“Our patients just respond to it a lot better,” said Rinehart. “With other systems in the past, when we contracted this service, we got calls for sedation. We feel that it has truly been exactly as they told us it would be.”

From an efficiency standpoint, Overlake Hospital’s newly established MR department has only recently purchased this one scanner and so they do not have a base to which they can compare their throughput. However, the increased patient comfort associated with the ultra-short open-bore design has significantly contributed to the department’s efficiency when one considers the alternative and the costs and time required to deal with claustrophobic patients. Without the need for lengthy coaching of patients and with sedation rarely, if ever, required, it is a more efficient and pleasant experience for both health care professionals and patients alike.

Additionally, Toshiba’s Atlas Technology eliminates the need to reposition patients during exams by utilizing integrated coil technology. This feature reduces exam time and is more comfortable for the patient. “It is easier because everything kind of just works together. ? We don’t have to move the patient around inside the bore,” added Rinehart.

From a cost standpoint, Rinehart explained that the reduced need for sedation saves the hospital money, since there is generally no reimbursement for a sedative given for an MRI procedure.

For Overlake Hospital, the ability to reach inside the bore to perform procedures on the patient, such as biopsies, is an additional benefit. “We want to be able to do some breast imaging and some other procedures, and we are finding that the large bore system that we currently have is going to actually help us with that because by the time you place on all the coils and get these patients in these special types of positions, especially if we do any interventional procedures, you need that open bore to do biopsies,” explained Rinehart.

Toshiba’s Vantage Titan ultra-short, open-bore technology has delivered on Overlake Hospital’s requirements for patient comfort and efficiency, without any reported issues in image quality. A tall order easily filled by an ultra-short system.

—Carol Dawson