At the Margins

CDI in outpatient settings: Are you ready for the challenge?

by Robert Linnander

We’re starting to get a lot of interest in outpatient clinical documentation improvement programs, whether in the ED, another ambulatory setting, or in physician practices. The more we start taking on risk for managing an entire population of patients across the care continuum, the more important accurate documentation across the continuum becomes. An accurate chart inflects outcomes for patients and impacts reimbursement.

Focus on quality to protect your revenue: The evolving role of CDI

While I think most people understand the importance of CDI in the outpatient setting, a recent Advisory Board survey found that only 6% of programs currently have an outpatient CDI program in place. Another quarter plan to establish a program in the next 12 months, but that leaves the vast majority with no imminent plans to create one.

Personally, I think that’s because it’s a really tricky thing to do. There are a lot of barriers to implementing this type of program. Here are a few of the biggest ones we’ve seen:

Not establishing clear goals

An effective documentation program has a well-defined mission. You need to ask yourself what you are trying to accomplish with outpatient CDI, and where that means you should start.

Difficulty measuring baseline HCCs

Outpatient payments are based on hierarchical condition categories (HCCs), so before starting an outpatient CDI program you need to get the data to understand your baseline performance on HCCs. Without this information you can’t prioritize focus areas for documentation improvement or judge whether your activities are having the impact you’d like.

Keeping up with the speed of outpatient care

Outpatient care occurs quickly. You don’t have the three-day patient stay to be sure you are nailing documentation, so an outpatient CDI program needs to be nimble to be successful.

Now, see how it's done

Just because it’s hard, though, doesn’t mean it can’t be done. To inspire you, here is an example of one hospital we have talked to that is doing outpatient CDI well.

What sets the top 10% of documentation programs apart?

Mona Hospital (a pseudonym) is in the process of rolling out an outpatient CDI program. One of their strategic goals is to build out an ACO capable of taking on quite a bit of risk, so they decided to focus first on their physician practices. After a thorough review of their performance, they learned they only had 33% coding accuracy on physician practice claims.

Clearly, there was a lot of work to be done, so they’ve moved to the second phase of their rollout: implementation. They have moved on to comparing the specificity and acuity levels between inpatient and outpatient to ensure they capture an accurate risk-adjustment factor for each patient. As they begin to take on more shared risk, they are monitoring their performance to ensure that this will be a sustainable model. We will continue to follow this program over time, but it’s safe to say that Mona Hospital’s experience clearly indicates a trend toward outpatient CDI. And with shared risk increasingly on our doorsteps, it’s not a moment too soon.

Rethinking clinical documentation improvement

Review the five key components of best-in-class clinical documentation improvement (CDI) programs and three next-generation strategies that will position programs for success as the health care system evolves toward risk-based payment models.

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