The Society of Interventional Radiology standardized reporting initiative is helping members with the integration of standardized and structured reporting into IR practice.
SIR advocates the adoption of practice paradigms that, above all, improve patient outcomes. Standardized reporting provides many benefits including a structured method to capture clinic data that can be customized to your clinic workflow. They also provide a seamless way to support your registry efforts.
These updated versions have been streamlined and revised to maximize efficiency and data capture. SIR provides a comprehensive range of over 140 IR procedure report templates, covering various IR procedures, including interventional oncology, neuro, pediatrics and more.
SIR Standardized Reports – Shorts
The SIR Standardized Reports Committee released three new informational shorts aimed at educating members on the value of standardized reports:
What’s New with SIR’s Standardized Reports: Mark Kleedehn, MD
Dr. Mark Kleedehn, Chair of the Standardized Reports Committee, discusses what’s new about the standardized reports, including new reports developed for neuro and pediatric procedures, interventional oncology reports and LI-RADS tumor classification, and how intra-procedure complications are captured.
Intro to SIR’s Standardized Reports and How to Use Them: Neil Halin, DO, FSIR
Dr. Neil Halin, Chair of the Standardized Reports Committee, provides an overview of the reports, and demonstrates how they can be customized.
SIR’s Standardized Reports for Pediatric Patients: Shellie C. Josephs, MD, FSIR
Dr. Shellie Josephs, pediatric interventional radiologist, introduces the new reports designed specifically for pediatric procedures and explains the importance of data capture for future research opportunities.
What are the benefits of SIR standardized report templates?
Reimbursement
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Increased charge capture and improved accuracy of charge capture
Required elements for coding and billing are frequently missing in the dictated report. If services are billed without these elements, you and your practice may be at risk if audited. Conversely, if services are not billed, you are losing revenue for the service you have provided. Standardized reports prompt you to document those required elements.
- Decreased denials
Denials occur for many reasons. Standardized reports can help reduce denials by directing you to include the appropriate documentation, diagnosis, and indication. When the ICD code supports the medical necessity for the procedure, the claim is paid. The claim is automatically denied if the ICD does not support medical necessity.
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Decreased report revisions
Coders may assist providers by asking for report revisions when they suspect key documentation is missing to ensure providers are appropriately billing for all services performed.
Standardized reports prompt you to include that key documentation in the initial report, decreasing billing costs and helping you get paid for all appropriate services provided. Unfortunately, many practices do not report revisions because they don't recognize the importance or do not have time. In addition, coders often do not have security in asking the providers to put the extra time in to revise the reports.
- Includes appropriate coding and billing language
Work performed is not billable if not documented. For example, providers do a lot of analysis and decision-making while looking at images and assessing the patient, but if that is not documented, it cannot be billed.
Standardized reports prompt you to include documentation for these services and the language required to document all required elements for billing a service.
Increased dictation efficiency
- Reports are designed to be highly efficient and quicker to use than narrative, free-text reports.
- They are also modular and can be customized to physician and practice preferences and needs; including customizing devices, methods, defaults, merge fields/auto-import of data from additional systems (ie. radiation dose), and if preferred, allowing for the inclusion of narrative and free-text modules
Increased referring physician satisfaction
- Report consistency enables referring providers to readily locate the necessary information.
Standardized lexicon
- Reduce subjectiveness, ambiguity, and variability; improve clarity and data quality.
- Allow users to "speak the same language," that is, to use standard terminology so that what one physician dictates means the same thing as what another physician dictates to describe the same disease, condition, procedure, or outcome.
Allows for registry participation
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As valuations for your services are developed by the RVS Value Committee (RUC) and by CMS, the methodology is shifting away from physician surveys which have been fraught with bias and inaccuracy. Instead, data is moving to real-world data (RWD) and real-world evidence (RWE) from registries and is currently used by other specialties. IR values cannot keep pace and be appropriately reflected without this data type.
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Registry participation is vital to your practice for patient access to IR care, payment, coverage, and for demonstrating value to your key constituents.
- Registry participation is proposed as a critical component of bonus payments for CMS.
- Registry data can be used to benchmark you/your practice, and that data is essential to your partners, hospital administration, referring physicians, patients, and payers. In addition, you will need data to demonstrate your skills and value in the future.
- Coverage of IR services will depend on published data as we are rapidly moving away from fee-for-service (FFS) payments to payments based on quality. Without RWD, RWE, and published data, coverage for services we "know" work will likely be reduced or denied. Therefore, your data is essential to publishing data that supports payment and coverage of IR services.
Download templates
Copyright Information
These reports are copyrighted by the Society of Interventional Radiology. Download and use of these templates indicates your agreement to use the files solely for your personal or facility use only. Users are not authorized to modify, change or otherwise improve the reports, except as indicated within the IR Standardized Reporting User Guide. Any reproduction, multi-use configuration or network distribution, transmission, publication, performance, broadcast, alteration, license, hyperlink, creation of derivative works or other use in whole or in part in any manner without the express prior written consent of SIR is strictly prohibited.
Questions
Contact virtex@sirweb.org with any questions or for more information.
*Note: Standardized reports are provided in both rtf and xml PowerScribe-ready formats. New reporting templates will be generated and existing templates will be updated on an ongoing basis. Email virtex@sirweb.org for the previous version 3.0 reports.
