Outpatient CDI: Who, What and Where in the Clinic / Provider Setting

1. Outpatient CDI: Who, What and Where in the Clinic/ Provider 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 due to workflow • 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. Physician Practices and Clinics This setting provides a significant opportunity for the introduction of CDI processes Increasing use of diagnosis codes to drive payment models (HCCs) Changes of CMS quality reporting metrics (MIPS) and (APMs) Prevalence of EMR systems that rely on provider input for the assignment of diagnosis and procedures codes – provides ample entry points for documentation improvement Supports accurate diagnosis and procedure code assignment, decreases the amount of time needed to complete the billing process and reduce the risk of claim denials or delays

7. Key Elements for Clinic Based Outpatient CDI Evaluation and Management (E/M) level of service CPT and HCPCS coding ICD-10-CM Medical Necessity Risk Adjustment Merit-based Incentive Payment System (MIPS) Denials Management Charge capture – all OP settings Claims and coding edits

8. Clinic Setting: Who is the Right Fit? • The outpatient CDI professional assists with: • Identifying the appropriate Evaluation and management (E/M) level • Validates the codes selected by the provider or offers the most specific code for consideration • Validates provider selected procedure (CPT) code or offers the appropriate code for consideration • Identifies or validates charges applied to the visit • Identifies the patient’s chronic conditions for accurate Hierarchical Condition Category (HCC) coding

9. 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

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

11. 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

12. 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

13. 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

14. Prospective Review Opportunities Chronic conditions needing annual documentation or more specificity Accuracy and completeness of problem lists Prep for preventive E/M services with update of active/chronic conditions

15. Retrospective Review Opportunities Verify correct sequencing of HCC diagnosis codes for billing Review for missing diagnoses, charges – injections/infusions and lab tests Denials management

16. 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

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

18. Metrics • Measure the impact of the clinical documentation specialist in: • Identifying missed diagnosis codes interventions or treatments • 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 diagnosis codes procedures, interventions, missed charges or medications

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

20. ROI Capture of missing office-based bedside procedures Capture of patients’ chronic conditions Increased provider severity and risk profile Reduced bill-hold times due to missing documentation or missing charges Additional or higher weighted HCC categories

21. 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

22. 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