According to a recent white paper published by the Association of Clinical Documentation Improvement Specialists (ACDIS), a 2016 survey indicated only a minority (approximately 10%) of hospitals currently have an outpatient CDI program. However, the survey shows outpatient CDI is becoming a higher priority. More than 20% of respondents reported plans to cover outpatient and/or physician services within 6 to 12 months.
As we begin a new year, outpatient CDI brings opportunities for healthcare providers to improve patient care, quality metrics and reimbursement across the continuum of 360 patient health. This article explores the rationale for outpatient CDI, barriers to consider and strategies for creating a successful tie-in to inpatient clinical documentation programs.
Why Create an Outpatient CDI Program
Healthcare providers that have realized benefits of inpatient CDI are well positioned to make the transition to the outpatient setting. The value proposition of implementing outpatient CDI is multifaceted, including the following benefits:
• Increased accuracy/use of the coding structure.
• Communication among the healthcare team increases patient care outcomes.
• Provider/facility profiling accuracy better demonstrates capabilities.
• Efficiency of patient throughput results in decreased LOS and patient risk.
• Quality scores and outcomes reduce the chance for penalties.
• Multiple crossover areas affected by documentation accuracy and departmental coding practice.
• Fewer denials — inpatient and outpatient.
• Accurate diagnoses — better weigh venues and determinations of care.
• Continuum of care coordination, accurately depicting the chronicity of care from inpatient to outpatient venues (HCC, SOI, ROM).
• Financial and profile accuracy.
• Accurate profiling (public and peer perceptions) of patient populations, physicians and facilities is dependent on accurate documentation and coding.
• Appropriate HCC, Professional Level, ICD 10-Diagnosis and CPT Rx assignments affect reimbursement for care provided by all facility types and healthcare teams.
• All coded data directly reflects the Inpatient Case Mix Index and Medicare Spending per Beneficiary aggregations.
Barriers to Implementing Outpatient CDI
With these benefits in mind, it’s also important to be aware of potential barriers as a basis for developing effective strategies. Categories for consideration include engaging the right people, conveying appropriate levels of knowledge to the right audience and gathering facts to understand your best approach/process.
Here are three factors to consider:
Buy-in from senior leadership and physicians. Senior leadership support is needed to initiate an outpatient CDI process. While some physicians may resist supporting outpatient CDI, they tend to show interest once they see results of a department/practice assessment — review for coding/billing accuracy. Preparation for the assessments and notification through proper channels can help gain support and compliance.
Data access. Though access to medical record data can be a barrier, a decisive plan will make it manageable. Data needed to identify coding and/or billing issues can usually be obtained from the physician or specialty departments. This will be one of the most time-consuming tasks of setting up the outpatient CDI process. Reaching out to a data analyst familiar with outpatient data collection or an internal outpatient auditor will be helpful. Ongoing data collection is necessary to measure results and monitor trends.
Staffing. Outpatient CDI challenges are different from those of inpatient CDI. Many staff will be unfamiliar with outpatient CDI in the areas targeted for implementation. Best practice is a gradual approach, engaging people who are knowledgeable in their areas and preferably have audit expertise and clinical/coding background. In addition, aspects specific to the outpatient program should be considered, such as productivity criteria and the number of staff required.
Where to Start
When initiating an outpatient CDI program, define your mission and expectations. Then identify supporters who will advocate for a progressive approach. Securing buy-in from senior leadership and physicians is critical.
Here are guidelines for getting started:
• Know your supporters’ priorities and expectations. Determine criteria for success based on opportunities to staff a certain number of hours in each department, or based on projected quality/denial/severity improvements.
• Identify participants who can promote optimal outcomes.
• Determine data access capability and what to look for in the data you review during the assessment process.
• Establish a process outline with step-by-step objectives.
• Build an outpatient implantation progression plan by department, specialty or provider.
• Set a progressive timeline — perfection is not a requirement to move forward.
• Define metrics, outcomes, dashboards and applicable distribution channels.
Achieving these steps requires collaboration among participants from various departments, particularly those that impact the revenue cycle, including health information management. Once you’ve begun the process, conduct ongoing evaluation, training and education to sustain progress and promote positive outcomes.
Outpatient CDI Priorities and Focus Areas
The standards for quality clinical documentation — inpatient and outpatient — are basically the same across the healthcare continuum. However, outpatient CDI is more complex because it depends on the type of services provided, which determines the payer/code methodology. The various code structures used in outpatient facilities include evaluation and management (E/M), modifiers, diagnosis codes (ICD-10), procedure codes (CPT) and hierarchical condition categories (HCCs).
Adding to the complexity, outpatient CDI encompasses a broad range of departments, settings and services including:
• Hospital outpatient departments
• Physician practices
• Ambulatory surgery settings
• Urgent care settings
• Clinic settings
Given such a diverse range, deciding where to focus can be overwhelming. For hospitals, the best place to begin is the emergency department, which manages a much higher number of encounters than the inpatient setting.
As ACDIS points out, “Assigning CDI specialists in the ED can help ensure physician documentation reflects the physician’s clinical judgment, demonstrates medical decision making, and captures the acuity of the patient, which will lead to fewer medical necessity denials. The ED is also the gateway to inpatient admissions, so clear documentation regarding the reason for inpatient care can assist with accurate assignment of the principal diagnosis as well as strengthen the medical necessity of the admission.” Other reasons for focusing on the ED include the following:
• The ED is usually on the same managed system as the IP EMR, or at least they are accessible.
• Assessment of historical data and medical records is vital. Look for opportunities:
• Identify denials, trends or focal points of codes (professional, procedural or diagnostic).
• Determine if diagnoses were not coded or should be coded at a different level of specificity to support medical necessity.
• Determine if procedures were performed and either not coded or coded inaccurately.
• Look for clinical indicators that might have been coded in a diagnostic format.
• Correlate diagnoses with an active and accurate problem list — critical for HCC risk scoring.
• ED documentation accuracy can influence the hospital inpatient severity/mortality and DRG depiction if the patient is admitted.
• Present on Admission (POA) status determination is usually determined in the ED.
• Value-Based Purchasing (VBP) exclusions are often identified in the ED.
For physician practices, cardiology and orthopedics are common focus areas. Larger organizations might choose ambulatory clinics or E/M services. Areas of priority depend on current commitments, staffing, patient volume/type, trends and resources.
A Bright Future for Outpatient CDI
In today’s value-based environment, outpatient CDI is essential, especially as physicians and their practices take steps to participate in quality metrics programs — now and more so in the next few years. Year 2017 promises to be an exciting time of growth and opportunity for all CDI affiliated professionals.
Steven Robinson, MS-HSM, PA, RN, SSBB, CDIP, is vice president for Clinical Revenue Integrity at RecordsOne, where he provides clients an ability to incorporate a Revenue Cycle Platform facilitating Prioritized Clinical Documentation Reviews, Multi-Department review participation, and Robust Drill Down / Actionable Analytics capabilities. Robinson holds advanced degrees and a unique understanding of the complete Clinical Documentation processes and its impact on Healthcare Facility Revenue Cycle. Credentials include: a Masters Degree in Health Services Management, Physician Assistant specialized in Orthopedics, Registered Professional Nurse, Six Sigma Black Belt, and Certified Clinical Documentation Improvement Practitioner. Steve’s experience includes Clinical Documentation and Quality Leadership for over 250 healthcare facilities nationwide managing Process Improvement, Throughput and Clinical Documentation consulting engagements.