The Society of Interventional Radiology Standardized Reporting Initiative allows IR practices to streamline reporting, which not only decreases denials and revision rates, but increases accurate charge capture and improves reimbursement rates. The customizable templates lessen the time needed to fill out reports, especially with routine procedures. IR Quarterly spoke with four physicians about their experiences with standardized reports.
How long have you been using standardized reports in your practice?
Suvranu Ganguli, MD, FSIR
Suvranu Ganguli, MD, FSIR: Approximately 2 years ago, our medical center hired a whole new group of IRs.
Mark G. Kleedehn, MD: We started using the reports in 2017, soon after they were made available through SIR. We initially used them primarily for central-line procedures.
Rajesh P. Shah, MD, FSIR: I have been using standardized reports in our practice for at least 5 years. They have been great. The report quality is consistent between attendings and it’s much easier to find information.
Mark G. Kleedehn, MD
How have standardized reports impacted your practice? Have your reimbursement rates improved?
SG: Since we are a new IR group, the hospital hired a well-known coding and billing company to help optimize our billing and reimbursement. From the physician side, since we were all using these standardized reports, there was very little the company found for us to improve.
Matthew S. Johnson, MD, FSIR: The person in charge of IR billing says that there is no question that billing has improved significantly.
Rajesh P. Shah, MD, FSIR
RS: We are periodically audited to make sure we are coding correctly. Switching to the reports has made it much easier to code, since we can easily match the CPT codes to specific lines in the standardized reports.
Have you noticed a decrease in report revisions since using standardized reports?
Tim Yates
Matthew S. Johnson, MD, FSIR
SG: When a standardized report is not used, those are the infrequent times that the coders send back a report saying we missed a billable element. There are very few revisions when using the standardized reports, and usually the ones that do get sent back are because someone erased something or did not use a standardized report.
MK: Yes, particularly with regard to using appropriate language for things like ultrasound-guided vessel access.
MJ: The number of such revisions was really small before utilization; now they are nearly non-existent.
Has your workflow improved since using standardized reports? How so?
SG: After using the standardized reports for a couple weeks, routine dictations take almost no time, especially if you customize the reports. After doing this, for some routine procedures you may only have to fill in one or two fields before signing the report. These reports are also great for group standardization, allowing everybody in the group to use the same templates.
MJ: For simple procedures, standardized reports greatly speed up reporting, as they comprise a series of familiar clicks. Standardized reports are even better for more complicated procedures, as they greatly reduce the quantity of free text, while still providing essential information.
RS: Workflow has definitely improved. The technologists write down all the important information and hand it to us at the end of the case. When we all had our own templates, we weren’t able to standardize that technologist report. Since switching, we’re able to use a single form. We also don’t need to spend time explaining the reports to the residents. They are very self-explanatory, so they’re able to dictate right away.
Do you feel standardized reports help your residents? If so, how?
SG: Since the standardized reports are vetted for coding and billing, residents won’t have to do dictate addenda because they forgot a billable element.
MK: Our residents love using the standardized reports since they provide the necessary structure of reports and are efficient to use. It also helps to have the billable elements built into the reports because this helps the residents learn what needs to be in the reports.
RS: I used to prefer narrative reports, but I would spend a long time correcting resident reports because they were unclear and often excluded important information. With the standardized reports, the information is all there. It is far faster to correct reports, and far fewer changes are needed. I cannot tell you how many residents have said how useful the reports are. They don’t need to guess what needs to go in the reports; they can dictate faster, capture all the key information, and the structure helps them understand the flow of the procedures. Because their dictations are completed right after the procedure, I’m able to sign off the reports on the same day rather than 1–2 days after the procedure.
What challenges did you experience when starting to use the reports? How did you convince others in your practice to use them?
MK: Commit to using the reports on a few commonly performed procedures for a couple of weeks before making any judgments about them. Although they look cumbersome to use, they are very quick and easy once you get used to them, particularly after you customize them.
MJ: I had to overcome the belief that I express things better than others, and that the nuances of my procedures required my artful exposition. That was clearly wrong. Standardized reports allow me to express the essentials of the procedures concisely and in a standardized manner. That’s what the people who read the reports want to read.
RS: The first version of the reports were long, tedious and not well received. But there was a lot of promise there that made us stick with it. The version 2.0 reports represented a huge improvement and made dictating faster, and versions 3.0 and 3.1 are even greater improvements. I never required anyone to use them. They just started using them on their own. No one has looked back since.
How have you customized your standardized report templates?
SG: I have customized my reports to basic inputs such as my name and regularly used material such as the different chest ports or G-tubes we place.
MK: We’ve moved some report elements around. For example, we’ve moved the impression to the bottom of our reports so they display properly when our EMR reformats the reports. Additionally, we are working to get the radiation and contrast dose to automatically import into the reports. It is important to realize that you can add as much narrative text as you want at the institutional or individual provider level and, of course, to any specific patient report.
RS: I’ve added narrative text in certain places, moved modules around or deleted them and defaulted fields. These reports provide flexibility while also allowing us to use the same terminology as IRs across the country, so it’s easy to understand someone else’s procedure.
What recommendations would you have for other IRs considering standardized reporting in their practice?
SG: For the future of our specialty, we all must adopt these standardized reports and join the VIRTEX data registry. If everyone understood what’s at stake here and why SIR is making this such a high priority, I think they would gladly do it.
MK: Take a few minutes to review the user guide before using the standardized reports so you understand how customizable they are.
MJ: Try them. They are certainly going to be used by the majority of people within the next few years, and they provide innumerable benefits.
RS: If you have any hesitation, just try it for a month. I have met very few people who went back to narrative reports. Nearly everyone I have met who has been critical of them has never even tried using them. We are IRs—we live on the cutting edge of medicine. These reports are cutting edge and can give us a leg up in quality, reimbursement and research. We really need everyone to be using these.
Standardized reports are the future of IR medicine, and we need everyone to take part. Adopt standardized reporting in your practice and join our VIRTEX registry today at sirweb.org/virtex.
For more information on standardized reporting, visit bit.ly/3Lh9nYB.
