Although CDI programs have typically been implemented in the inpatient setting, many organizations are beginning to turn their attention toward outpatient documentation as well. That’s because many of the same documentation deficiencies occur in both settings. Poor outpatient documentation—particularly in the emergency department (ED) record—can also affect inpatient code assignment. As third-party auditors continue to scrutinize both inpatient and outpatient documentation, it makes sense to incorporate outpatient charts into CDI reviews or establish an outpatient CDI program, when possible.
Creating buy-in for your program
Like any major initiative, HIM professionals need to be able to explain to the administration why an outpatient CDI program is necessary. Begin by talking with your organization’s patient account representatives and claim editors. They’ll likely provide you with a breadth of information that you can use to justify your program. For instance, you’ll quickly learn that most denials are due to lack of documented medical necessity. National and Local Coverage Determinations define various codes that support medical necessity. The good news is that CDI specialists working in the emergency department and other outpatient areas can teach physicians about medical necessity and the types of diagnoses that justify certain procedures.
Don’t stop with medical necessity. Consider the following top three reasons to implement an outpatient CDI program:
1. Reduce claim denials – Although medical necessity contributes to many denials, it’s certainly not the only reason why claims are denied in the outpatient setting.
2. Improve the accuracy of the present on admission (POA) indicators – The ED record serves as the foundation for assignment of the POA indicators. Coders refer to this documentation when determining whether a patient presented to the hospital with a particular condition or whether he or she developed it after admission. POA indicators are important because they affect a hospital’s volume of hospital-acquired conditions (HAC). Coders need accurate and thorough documentation in the ED record so they can assign the POA indicator correctly. The CDI team should work with physicians to ensure that clinical indicators are documented appropriately. CMS will not pay the CC/MCC DRG for those selected HACs that are coded as “N” (not POA) for the POA Indicator. It also won’t pay the CC/MCC DRG for those selected HACs that are coded as “U” (documentation insufficient to determine the proper indicator) for the POA Indicator.
3. Enhance coding accuracy – As is the case in the inpatient setting, improving outpatient documentation will directly affect coding accuracy. When outpatient documentation is insufficient, organizations will notice a pattern of incorrect coding that can lead to a negative impact on reimbursement and data integrity. The outpatient CDI team must work with physicians in the ED, observation, and same-day surgery units to ensure that documentation supports accurate code assignment.
Once you’ve established the justification for creating an outpatient CDI program, determine your focus areas. To do so, use claim denial and edit data to identify the issues that require immediate attention.