CDI in the Outpatient Setting

While inpatient services have experienced decreasing volume, including fewer admissions and shorter lengths of stay, the volume of outpatient service visits is steadily increasing – as is the complexity and associated financial risk to the provider. Clinical documentation improvement (CDI) programs are following a similar trajectory in that CDI programs have become ubiquitous in the inpatient setting, but have yet to make a substantial footprint in the outpatient setting.

When it comes to slow adoption of CDI programs in outpatient settings, some healthcare organizations report that the challenge resides in the sheer volume of outpatient departments while others state a lack of understanding of the financial risk in these areas. Moreover, the volume of the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) that provide coverage requirements create management and workflow challenges for healthcare providers. With patient care volumes trending in favor of outpatient services, there has also been an increase in outpatient RAC reviews and denials. As a result of these various threats and changes, many in the healthcare industry have begun to realize that the time is right to start focusing on CDI for outpatient services.

Preparing for ICD-10-CM Impact
If denial of claims and the threat of RAC audits aren’t enough to spur interest in the need for an outpatient CDI program, the transition to ICD-10-CM presents yet another reason to consider CDI. ICD-10-CM offers a very real and pressing challenge due to the volume of code changes, revised coding guidelines and level of required specificity of both documentation and codes.

As such, outpatient service providers should consider adopting the following clinical documentation best practices when it comes to ICD-10-CM:

• Ensure training addresses relevant, real-life patient encounters, using hands-on clinical documentation and coding exercises;
• Implement or update electronic health record (EHR) templates that identify diagnosis and anatomically specific ICD-10 attributes;
• Support documentation for new ICD-10-CM codes, such as underdosing of medications;
• Eliminate coding cheat sheets, otherwise unspecified codes will persist and there will be no incentive for documentation improvement; and
• Base CDI initiatives on the unique needs of your providers, coders and staff.

Getting Started on Outpatient CDI
Outpatient CDI should be focused initially on areas most impacted by denials. Analyzing denial trends and patterns in the outpatient setting can uncover services that require improved documentation. Through this assessment, outpatient CDI programs can tackle high dollar denials and align with an organization’s revenue cycle processes for real, quantifiable benefits.

For example, cancer treatment is an area that many organizations are starting to review for CDI due to its associated risk. High cost medications are a prime target for RACs, which often include cancer drugs. When documenting medication, the start and stop time needs to be noted for compliance. In addition, coverage indications for expensive chemotherapy drugs and adjunct therapy drugs are highly complex, limiting certain medications to specific timeframes, dosages and diagnoses. As such, it is critical that the detailed nuances of medication treatment are captured in the patient’s record in order to ensure that these expensive cancer treatment medications are fully reimbursed for patient and provider alike.

Resolving Clinical Documentation Workflow Hurdles
Many clinical documentation issues can be resolved by educating clinicians and coders, improving processes and workflows, and enhancing EHR templates designed to capture co-morbid conditions and severity of illness.

In the outpatient setting, technologies such as computer-assisted physician documentation and computer-assisted CDI will be critical components in managing the uptick in patient volumes and identifying risks in real-time. Computer-assisted physician documentation provides critical feedback to the provider at the point of capture so that clarifications do not require a time consuming query process from the CDI specialist.

In addition, computer-assisted CDI will enable CDI specialists to increase their rate of review and audit reports rather than starting from scratch with each case. This allows the CDI specialist to review more cases and focus on value-added opportunities rather than time consuming activities and routine cases. While the review will not be “concurrent” in the outpatient setting because of the short timeframe for visits, key documentation elements can be identified before the bill is dropped and while those essential thought processes are fresh in the providers’ mind.

Automated, intelligent technology that integrates with current workflows coupled with the oversight of outpatient clinical documentation specialists will allow organizations to monitor and identify insufficient documentation and lack of specificity that creates compliance risk and generates denials. While most hospitals do not have the resources to establish outpatient CDI programs for every department, healthcare organizations can start by introducing CDI for high risk services such as cancer treatment or cardiac procedures. Organizations can identify these high risk outpatient service areas through a baseline assessment and by reviewing charts for problem areas.

Measuring the Impact of the CDI Program
Measuring the impact of an outpatient CDI program can also be more challenging than in the inpatient environment. While case mix index (CMI) is the key metric for inpatient encounters, outpatient impact focuses on improving compliance and reducing denials. Your outpatient CDI analysis should revolve around three areas:

• Denials measurement: Look at the daily, weekly, monthly, and year-to-date volume of denials and compare historic denials to the current number
• Rework measurement: Measure the dollar amount and volume of rework needed to resubmit claims
• Quarterly chart reviews: Perform regular chart review to determine the quality of clinical documentation. How many orders require clarification or rework? How many denials and appeal letters have been generated? What percentage of cases has documentation deficiencies?

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As with the inpatient setting, providers need to be educated on the rationale behind improved documentation and how it benefits not just the hospital, but more importantly, the patient. Collaboration, education, technology and a streamlined, near real-time query process can help outpatient services tackle their most pressing documentation issues. Still, it’s important to remember that a solid CDI program must minimize disruption to the physician workflow; automate processes where feasible so that physicians can remain focused first and foremost on patient care.

Managing documentation improvement in the outpatient setting can be a daunting endeavor at first glance. Still, the benefits of bringing CDI into high-risk and high-reward service areas will make the effort worthwhile. When charts reflect accurate severity adjusted profiles, organizations will reduce the number of medical necessity denials, align with value-based and risk adjustment payment models, and be able to negotiate fair contracts and meet the demands of accountable care (ACO) initiatives.

Elaine King is an outpatient payment specialist and an AHIMA-approved ICD-10 CM/PCS trainer for Nuance Communications Inc.

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