Outpatient CDI: Who, What and Where in the Hospital Setting

1. Outpatient CDI: Who, What and Where in the Hospital Setting Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA Manager, HIM Consulting Services, UASI Tara Bell, MSN, RN, CCDS, CCM Manager, CDI & UR Services, UASI

2. Objectives Recognize the necessary skill sets for OP CDI staff Assess the required clinical and coding knowledge needed for OP CDI Determine the needed data analytics for assessing OP CDI needs

3. Why Outpatient CDI • Pre-emptive defense against charge denials • Creating a ‘clean claim’ • Reduced denials • Presents distinct challenges from inpatient CDI • Shorter LOS • Increased volume • Concurrent review likely not an option • Prospective review, and • Retrospective review prior to billing

4. Why Outpatient CDI? • A variety of opportunities exist regarding the review of provider documentation completed during an outpatient or provider encounter • Multiple drivers pushing the implementation of outpatient CDI • Medical necessity • Patient status • Risk Adjustment (RA) and Hierarchical Condition Categories (HCCs) • Coverage criteria to ensure appropriate reimbursement

5. Why Outpatient CDI? • Implementation of outpatient CDI requires a thorough analysis of the needs of the organization • Financials • Underperforming outpatient areas • Denials specific to outpatient areas • Patient status issues • Medicare Advantage (MA) providers • MA patient population risk adjustment scores • Annual evaluation of RA data • Establish priorities for implementation

6. Where is CDI? • Hospital based services outside of the inpatient setting • Emergency department services • Ambulatory surgery • Observation services • Home Health • . . . And more

7. Emergency Department Services Fast-paced, high volume care setting with an extreme variety of patient conditions being treated Reporting includes both professional and facility level coding for services, procedures and medical supplies Patient transfers from the ED to observation and inpatient status create opportunities for CDI facilitation of accurate and compliant documentation Also provides an opportunity to capture and maintain the clinical severity of illness from the initial entry point through to care in other settings

8. Ambulatory Surgery • Free-standing facilities or hospital-based departments performing scheduled same day surgical procedures • Key areas of documentation include: • Pre-surgical H&P • Anesthesia evaluation • Intra-operative notes • Procedure/Operative notes • Post-operative assessment and re-assessment • CDI is necessary to support capturing the diagnostic statements for medical necessity along with complete medical history, and intra-operative or post-operative complications

9. Observation Services Providers may need additional time to assess the patient’s symptoms response to treatments, or clinical evaluations of lab results to determine the appropriate discharge plan or decision for admission CDI professionals can help ensure the documentation clearly states the conditions the patient is being admitted for Facilitate the documentation bridge between the outpatient observation record and the admitting H&P

10. Home Health Care (HHC) • HHCs are crucial within the continuum of healthcare providing such services as: • Wound care • IV therapy • Injections • Therapy – PT, OT, ST • Outcome and Assessment Information Set (OASIS) – tool used for documentation of HHC services • CDI professionals assist in the capture of all data elements needed to complete the OASIS assessment • Must be completed within five days of the start of HHC and other intervals

11. . . . And More Interventional Cardiology/Radiology Radiation Oncology Physical Medicine services Broad array of patient care settings for outpatient services Evaluate which areas may provide the most significant opportunities for documentation improvement activities

12. Key Elements for Hospital-based Outpatient CDI ICD-10-CM CPT and HCPCS coding Medical Necessity Risk Adjustment Hospital Outpatient Quality Reporting Program (OQR) Denials Management Charge Capture

13. Who is the Right Fit? • Utilize the clinical and coding expertise of the CDI profession to provide information regarding: • Specificity of diagnoses • Identifying procedures to be coded • Identifying medical necessity issues for tests/procedures ordered • Assisting with quality metrics and physician profiling • Identifying chronic conditions that impact the severity profile of the patient

14. Who is the Right Fit? The outpatient CDI professional requires: • Strong outpatient regulatory and coding understanding • Coding knowledge • Coding and sequencing guidelines • Reporting requirements, claims submission/correction • High volume chart review

15. Who is the Right Fit? The outpatient CDI professional requires: • Strong clinical knowledge background • Recognize what constitutes monitoring/treatment of specific conditions • Credibility with providers • Care coordination, disease management

16. Who is the Right Fit? • The outpatient CDI professional can be: • Coding professional with strong clinical knowledge base • CDI professional with solid outpatient coding understanding

17. Who is the Right Fit? Clinical Documentation professional and/or Coding professional Less medical information to review Greater volume of cases Productivity and staffing may vary according to the outpatient setting Consider the unique needs related to each setting when determining staffing

18. Who is the Right Fit? • Clinical Documentation professional and/or Coding professional can be utilized dependent on outcome focus • Pre-Hire assessment to determine knowledge base • Screening questions during interview • Credentials • CRC Certified risk adjusted coder • CDEO Certified documentation expert outpatient • CCDS-O Certified Documentation Specialist-Outpatient

19. Prospective Review Opportunities Chronic conditions needing annual documentation or more specificity Medical necessity review related to LCDs and NCDs

20. Retrospective Review Opportunities ED documentation review of testing to establish medical necessity Case review for Observation encounters Verify correct sequencing of HCC diagnosis codes for billing Review for missing charges – injections/infusions and lab tests Denials management

21. Data, Data, Data • Organizations should gather data to develop a focus on key areas for improvement • Metrics: • Improved quality indicators that track increased compliance with quality measures or improved financial outcomes • Assists in identifying areas of opportunity

22. Data, Data, Data . . . • Organization’s unique needs in program design • Volume of denials for medical necessity • Outpatient surgery medical necessity denials • Are you part of an ACO? • Do providers participate in Medicare Advantage programs? • Do providers participate in any value-based payment programs?

23. Metrics • Measure the impact of the clinical documentation specialist in: • Identifying missed interventions or treatments • Capture and provider documentation of time-based codes (infusions vs. push) • CDI specialist metrics should include: • Risk adjustment factor (RAF) impact of the clinical documentation review process • Number of communications placed • Type of communication clarifications placed • Rate of provider communication agreement • Impact of identified procedures, interventions, missed charges or medications

24. Metrics • General ambulatory CDI program metrics may include: • Denial rate • Financial impact of denial rate • Gross increase in RAF scores

25. ROI • Reduced inappropriate inpatient admissions • Reduced time in Observation status • Admit to inpatient status • Discharge home • Capture of missing Emergency Department bedside procedures • Capture of patients’ chronic conditions • Increased provider severity and risk profile • Reduced bill-hold times due to missing documentation or missing charges

26. Best Practices • Optimal staffing levels • Various outpatient locations • Various provider specialties • Collaboration with providers, revenue cycle team • Define and share goals and objectives • Workflows supporting quality and financial goals • Accountability

27. References 6 Things to Know When Preparing to Implement Outpatient CDI; Health Information Technology; November 20, 2017; https://www.beckershospitalreview.com/healthcare-information-technology/6-things-to-know-when-preparing-to-implement-outpatient-cdi-2.html 2008 Final Rule – 42 CFR Parts 410, 411, 412 et al – published on November 27, 2007 Outpatient Clinical Documentation Improvement (CDI): An Introduction; ACDIS whitepaper, May 2016 AHIMA Outpatient Clinical Documentation Improvement Toolkit