Documentation and Reimbursement for 3D Printed Anatomic Models and Guides

Medical record

The multiple steps of care including history, orders, vital signs, medications, lab, imaging and testing results, consultations, biopsies, procedures, clinical outcomes, and care plans are documented in the current comprehensive medical record which is largely in an electronic format. Most importantly, this record serves as the patient’s clinical history for all care providers in order for them to give the patient optimal care. Information is also included in the medical record to describe the effort that goes into a patient’s care such as which type of healthcare workers are involved, the amount of time spent, and the materials and techniques used.

Documentation of 3D printed anatomic models is largely reflective of documentation for other medical services. It starts with an electronic order which lists the important information to know for planning. This includes patient name, medical record number, ordering physician and contact number, indication or diagnosis, anatomic structures to include, date needed by, sidedness, and whether imaging has been performed yet. Additional questions on mirror imaging, need for guides, material, and color preferences are also helpful. For the best understanding of what is needed, it is important to talk directly to the ordering physician before starting.

Data storage organization

Secure backed up large capacity computer storage is needed to keep each patient’s imaging data, segmentation, and computer-aided design (CAD) files, photos, and any videos which are created from the files. Other patient-specific information such as quality assurance measures can also be kept in these files. This information can be organized and listed by the patient’s name and clinic number similar to filing in a classic medical record ( Fig. 8.1 ).

Dictation

A formal dictation is placed in the medical record to document the creation of the model. The dictation can be organized in any number of ways depending on each institution’s dictation guidelines and software. Completing the dictation can be easier if it is created with as many pick lists as possible to choose options from. Most dictation software has some type of pick list options. A dictation format similar to that used in interventional radiology procedures could be considered as it has a similar organization of history and indication, findings, procedural technique, and final impression. The dictation report can begin with a short history and specific indication for the model. This would include the basic information from the request form including general anatomic structure, side, type and date of imaging used, contrast used, and laterality as needed.

The procedural technique would go through the multiple steps of model and guide creation which would make up the largest part of the dictation. This would include segmentation and CAD processing details including the design time with the level of staff that completed these and specific details including how many and which anatomic structures are in the model. The dictation would also include the type of 3D printing technology, specific printer, and type of materials and colors used to create the model. Postprocessing procedures including cleaning and curing time would also be part of the technique. How and where guides are sterilized should be documented. Quality control measures done to check accuracy of the model and guides can also be noted.

The final impression would be a short synopsis of what type of model was created and for what use. Additional information could include date of model delivery, to whom it was delivered, and what department they are in. Color photos of the final model may be placed both with the dictation and in the imaging section of the medical record.

The extensive and detailed information in the dictation reflects the work, skill, and effort put into creating the models. These data are invaluable and are used for patient care, quality improvement, and to potentially include in research studies and registries. Importantly, components of the clinical and technical documentation are used to determine the appropriate level of reimbursement for services rendered by both government and private healthcare insurers.