As prolific changes happen across the healthcare revenue cycle, many organizations and providers are recognizing the benefits of clinical document integrity (CDI). Recent changes in reimbursement methodologies such as HCCs and quality of care measures have led to an increased focus on outpatient CDI. Usually, outpatient CDI includes reviewing encounters in the emergency department, acute care, ambulatory clinics, observation, and physician office clinics. It’s a very broad definition that can consist of any CDI efforts not associated with an inpatient encounter. There are many factors to consider when implementing or upgrading a program. Let’s talk about a few of the important components.

Code Sets

Even though the ICD-10-CM code set remains the same in both an inpatient and outpatient setting, the outpatient setting does have some additional specifics. For example, outpatient claims are paid under the Outpatient Prospective Payment System (OPPS). These visits also rely heavily on “hard-coded” coded items. Hard-coded items are built into a facility chargemaster and assigned by front-end staff rather than a coder. These items are usually assigned using current procedural terminology (CPT) codes. In addition, the role of Healthcare Common Procedure Coding System (HCPCS) codes is equally important in reimbursement. 

Skill Set

CDI specialists working in the outpatient area focus on documentation, ICD-10-CM codes, E/M Codes (CPT), quality measures, and risk adjustment. Qualified individuals should have advanced knowledge of all ICD-10-CM, CPT, and HCPCS code sets and guidelines and various Hierarchical Condition Category (HCC) models such as CMS-HCC, HHS-HCC, and RX-HCC. A strong clinical background and knowledge of OPPS, STARS Program, and/or HEDIS are also beneficial. Perhaps one of the most important skill sets is the ability to communicate with physicians effectively and efficiently. These staff members must be able to clearly and concisely interact with measures and documentation requirements. Above all, outpatient CDI Specialists must have the analytic skills to look for what is not documented or what is missing from the visit note but may be present based on clinical indicators.

Emergency Department (ED)

When considering CDI in the ED, two key points are the high throughput volume and the brief encounter length. Ideally, the CDI Specialists work quickly with clinical staff to clarify documentation and medical decision-making and adequately capture the severity of the patient’s condition. The ED also serves as a main entry point for inpatient admissions. The prompt review of these encounters ensures that all important clinical information and decision-making is well documented within the record, strengthening the support for an inpatient or observation stay. Due to the high patient volume, organizations may focus on specific areas such as inpatient admission, accurate E/M services, or patients that stay longer than 5 hours. A retrospective audit may assist the organization in prioritizing its immediate areas of opportunity. 

Acute Care Ambulatory Clinics

These clinics include specialties such as Infusion Clinics, hospital-based physician clinics, ambulatory surgery, and wound care services. Organizations can focus on all settings or just one area with a high patient volume or a high risk for errors. Essential indicators include assigning appropriate CPT codes for procedures and evaluation and management services, HCCs, and other diagnoses, contributing to the complete and accurate patient story. These services can also be considered high volume, meaning that many patients engage with these entry points daily. CDI reviews may also be completed retrospectively to validate code assignments and ensure the capture of the appropriate level of care, services, and diagnoses.

Observation

Organizations have struggled with observation status for several years, and it doesn’t seem to be getting any easier. Once you understand the rules, something changes. Observation CDI can provide an immediate return on investment for organizations. From a reimbursement standpoint, observation CDI can validate total hours and clinical severity and ensure that the patient is in the correct status. Although patients may be on an inpatient unit, they are still billed under OPPS and, more specifically, reimbursed through the comprehensive ambulatory payment classification (APC) rate. These patients typically stay up to 48 hours or two midnights; however, it does require a minimum of 8 hours. Time is billed at an hourly rate and stops if the patient leaves the unit for a procedure that is separately billable. Payers are increasingly encouraging organizations to place patients in observation status for more extended periods. A CDI program could work proactively with case management and providers to ensure medical necessity and CMS guidelines are met when determining patient status orders.

Physician Office Clinics

Large physician practices continue to grow as physicians merge to run one large single practice rather than a small single practice. Providers paid under Medicare B, Medicare Advantage, or Medicaid are under increased scrutiny. As ACOs continue to grow as a reimbursement model many physician groups are choosing to implement Outpatient CDI Programs to assist in demonstrating the value and complexity of their patients. In addition to providing the appropriate E/M level, CDI assists physicians in telling the accurate patient story, including those chronic conditions contributing to the HCC model. Physicians also must have the appropriate components or time to support their medical decision-making. Outpatient CDI provides additional support to physicians in accurate documentation, capturing all diagnoses, and assisting appropriate E/M levels which results in a complete claim and translates to accurate reimbursement promptly.

Summary 

Clinical documentation and clinical coding validation have become increasingly complex as stringent payer regulations, compliance requirements, and pay-for-performance have been implemented. Creating a team of dedicated qualified staff can assist in achieving accurate reimbursement and maintaining coding compliance. To determine where to focus your efforts or assist in developing your outpatient CDI program contact CSI Companies for a sample pre-bill chart review or to learn more about our complete Immersive Practice Workflow Assessment.