Purpose or Case Report: At our children’s hospital, we deployed clinical decision support (CDS) software to support appropriate use of imaging. The software is primarily based on ACR appropriateness criteria. To determine if by using CDS, lower rates of payer claim denials could be expected, we evaluated rates of payer claim denials based on CDS score prior to CDS go-live.
Methods & Materials: This study was HIPAA compliant and exempt from IRB approval. The specified indications on all CT exams performed 9/18/18 to 6/30/19 were rated by ACR-CDS software in silent mode; no feedback was presented to ordering providers. Claim denials for billed CTs were retrieved from hospital billing through 9/13/19. Rates of payer denials were analyzed for 5 categories: 1-3 red (not appropriate), 4-6 yellow (may be appropriate), 7-9 green (appropriate), indication not found (option the provider can use if available structured indications are not appropriate), and no score for the provided indication in CDS. Chi-square test was used for statistical significance of denial rate differences. Additionally, reason for payer denial was evaluated to identify any denials attributable to the CT exam’s indication.
Results: During the time period, there were 11,038 billed CTs: 1597 (14.5%) red, 1906 (17.3%) yellow, 5140 (46.6%) green, 1923 (17.4%) indication not found, 472 (4.3%) no score. The payer denied claims in 1,177 (10.7%): 181 (11.3%) red, 200 (10.5%) yellow, 533 (10.4%) green,198 (10.3%) indication not found, and 65 (13.8%) no score. There was no statistically significant rate difference in denials based on CDS category (p = 0.18). Of the red (not indicated) exams, there were no denials attributable to indication. In all, 2 denials were attributed to indication, both on exams with green indications.
Conclusions: At our institution, there was no correlation between CDS appropriateness category and payer denials. Reason for denial of red (not indicated) CT exams was not due to inappropriate indication. At this time, payer criteria is not aligned with appropriateness criteria. In the short term, a change in denial rates for billed CT exams following CDS go-live is not anticipated.