Outpatient Clinical Documentation Improvement . . . Achieving a Successful Program (Part I)

With more and more patient services moving to the outpatient setting we need to be ready and prepared for the implementation of an outpatient (OP) Clinical Documentation Improvement/Integrity (CDI) program.

CDI has a strong footprint in the inpatient hospital setting where there are longer periods of time of patient interaction, longer time to review the health record and also a primary focus typically on diagnosis due to the length of stay (LOS). In the outpatient setting the time the patient is seen for the encounter/visit is much less, in fact it is extremely limited. There also is a variety of outpatient settings and types of encounters/visits that may or may not be conducive to a CDI program. The American Health Information Management Association (AHIMA) and Association for Clinical Documentation Integrity Specialists (ACDIS) have a wealth of resources and tools to help with CDI.

To start, there are several key components that need to be either in place or addressed in an OP CDI program to be successful, these include but are not limited to the following (this article will discuss several of these):

  • Conduct a pre-program Assessment
  • Have a Mission Statement
  • Determine the outpatient Setting and Goals of your program
  • Develop written Policies and Procedures
  • Establish Metrics
  • Secure Staffing
  • Focus on and build a culture of Compliance and Integrity

Just like in the inpatient setting, in the outpatient setting, the CDI program should always ensure that:

  • Proper documentation ensures patients get items/services that are reasonable and necessary
  • Proper documentation supports proper claim payment
  • Proper documentation supports favorable medical review decisions

There are several different outpatient settings to consider for CDI that might include any of the following:

  1. Hospital Emergency
  2. Physician Emergency Services
  3. Observation (Hospital)
  4. Observation (Physician)
  5. Outpatient Surgery (Hospital)
  6. Outpatient Surgery (Physician)
  7. Ancillary Services
  8. Physician Clinic and/or Office encounters

The initial step is to conduct an assessment, which includes gathering and reviewing some outpatient clinic or departmental data that can help in determining what the focus of your CDI program will be and identify the key areas for improvement. This would include common diagnosis (top 20-25 most frequent), common CPT (top 15-20 most frequent), and common HCPCS (15-20 most frequent). Another data element to gather and review would be the top five most frequent modifiers. Also, obtain and review your organization’s outpatient department volume of denials for medical necessity, CPT, Modifier, etc. Of course, monthly encounter volumes will also be important to obtain.

During the assessment process you will want to interview several outpatient setting directors or the specific OP department director to gather more information and details. Some common questions to ask may include the following:

  • EHR? Or Paper medical record?
  • Is your organization part of an accountable care organization (ACO)?
  • Do your providers participate in Medicare Advantage programs?
  • Do your providers participate in any value-based payment programs?
  • Do providers enter/pick the Dx or CPT codes?
  • Do you conduct daily charge validation?
  • Do you get notified when there is a denial of an encounter?
  • Do you have credentialed coding professionals performing the coding currently?

As you can tell, there are many important components and steps to starting and implementing a successful OP CDI program. We will continue with the discussion of achieving a successful Outpatient CDI Program, and look as additional components to put in place.

References: AHIMA CDI Tool Kit 2016; AHIMA; AHIMA/ACDIS 2019 Practice Brief: Guidelines for Achieving a Compliant Query Practice; https://acdis.org/system/files/resources/outpatient-cdi-intro.pdf

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AHIMA Approved

This program has been approved for continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.