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

Outpatient Clinical Documentation Improvement/Integrity is gaining more and more attention. Having a successful program involves preparation, planning and executive. As we discussed in Part I (in the previous RMC newsletter) there are several key components to an OP CDI program. A best practice is to identify one setting that you wish to focus your CDI program on to start, remember to take it slow at first. When reviewing volumes, keep in mind that your staffing levels will be impacted by the department or area you choose.

Create a “Mission” statement for your OP CDI program. A mission statement should be short and focused on a few key aspects and purpose of your program. The following is an example of an OP CDI Mission statement that gives you an idea of what might be included:

Communicate and Educate providers in obtaining complete and accurate outpatient documentation of fully informed coordinated care within the health record.

Determining the focus of your OP CDI program is something that may be tied to budget, staffing, and/or expected revenue impact. For the outpatient setting, there is ICD-10-CM (diagnosis), CPT, and HCPCS codes to consider, the following maybe taken into consideration:

  • Diagnosis (HCCs) and/or Medical Necessity
  • CPT E&M (facility-based, often via EHR)
  • CPT ER Procedures (Hospital and Physician)
  • CPT ER I&I (Injections/Infusions) – Hospital
  • Other OP areas to consider:
    • Diagnosis and CPT I&I Chemotherapy
    • Outpatient Surgery: Diagnosis and CPT
    • Ancillary Services: Diagnosis, CPT (Charge Capture)

Developing specific goals for your OP CDI program often needs the input of your own departmental staff, as well as the leadership/management of your practice or facility (i.e., Revenue Cycle Director, Medical Staff Director, Chief Financial Officer, Compliance Director, etc.). Your goals will be linked to the metrics and data you collect. Here are a few examples of OP CDI goals:

  • Identify and clarify missing, conflicting, or nonspecific provider documentation related to diagnoses and procedures
  • Support accurate diagnostic and procedural (CPT) coding, leading to appropriate reimbursement
  • Promote health record completion during the patient’s course of care, which promotes patient safety

OP CDI metrics such as improved quality indicators that track increased compliance with quality measures or improved financial outcomes can assist in identifying areas of opportunity. Specific metrics need to come from the data that is available to be collected and/or obtained. Gathering and tracking your metrics should be daily, weekly, monthly, and annually. Here are some examples:

  • Total encounters available to review and Actual CDI reviews (include percentage)
    • By financial class, e.g., Medicare payer vs. non-Medicare payer
  • Physician clarification impact percentage
    • The number of clarifications placed by a CDI that had an impact on the encounter
  • Severity clarification percentage
    • The number of clarifications that resulted in a severity change
  • Physician response to CDI specialist
    • The number of times a physician responds to a CDI question
  • Physician response turnaround time (may identify a bill-hold issue)
  • Physician agreement with CDI specialist

Having in place strong written policies and procedures (P&Ps) can only strengthen your OP CDI program. Although it can be time-consuming to write the P&Ps they will serve as a foundation for your program and staff. P&Ps provide guidance on your activities, duties and processes which is essential for consistency, continuity, and compliance. Some P&Ps to consider drafted are:

  • CDI Staff Orientation and Training
  • Query Form and Process – verbal or written; paper or electronic
  • Query Escalation
  • Query Retention
  • Statistics and Data Collection
  • Quality and Review (Audit)
  • Physician Education

It is strongly recommended that the AHIMA Practice Brief, “Guidelines for Achieving a Compliant Query Practice” be utilized and followed for your P&Ps. This Practice Brief is an industry standard and it can also provide some example of query forms/template that will be useful.

As you can see there is lots of parts and steps to developing a successful OP CDI program, some are not discussed in this article (i.e., staffing). Clinical documentation will only get more specific, more detailed, and more compliant if we have a focused CDI program in place to address it.

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.