Tuesday, September 26, 2017

Revamping the Outpatient Setting with Clinical Documentation Improvement

by Kayla Dickard, RHIA, CCS 

When we think of clinical documentation improvement we correlate that with concurrent reviews on inpatient records, but with the increase of outpatient visits there is a growing trend for outpatient clinical documentation improvement. Per CMS, between 2006 and 2014 outpatient visits per beneficiary have increased by 44%, while inpatient discharges per beneficiary have decreased by almost 20%.  Another major reason to implement CDI is to optimize reimbursement. In 2015, CMS announced its intent to shift from fee-for-service into value-based strategy. This will allow for monetary incentives to providers who demonstrate high quality, efficient care through their performance. As these programs progress, providers will also be financially penalized for poor performance. CDI will play a major role by verifying documentation supports quality of care provided. Also, with the use of electronic health records there are many ways for CDI specialists to improve the functions to the physicians needs for documentation requirements. 

There are numerous benefits of clinical documentation improvement, of course the main one being to increase documentation specificity. Having this greater specificity will allow for accurate code assignment, reduce denied claims, and reduce any other barriers to billing. CDI in the outpatient setting to review documentation will also decrease the additional documentation requests and increase compliance to billing and coding regulations.  Also, having correct and current documentation will correspond with an increase in quality of care to the patient and provide accurate quality scores. Interestingly, according to a recent article published in Journal of AHIMA, first research of its kind has established a link between patient outcomes and uncoded diagnoses in the patient record. Patients that have an uncoded diagnoses account for higher utilization of inpatient and emergency services, and experience less than optimal patient outcomes for chronic diseases such as congestive heart failure, hypertension, diabetes, and dyslipidemia. Therefore, CDI can play a part in verifying the physician is documenting all conditions and there is support to code in outpatient visits.

Although there are many advantages to an outpatient CDI program, there are some barriers that will need to be addressed. First, the short length of stay is going to be a challenge. Compared to the inpatient setting where CDI may have days to review a record, now CDI must review the documentation before it gets to the coders in a short window of time. Also, there are many more outpatient visits compared to inpatient discharge. So having this large of a case volume will be something to consider. Also, when starting a CDI program in the outpatient setting there can be a lack of focus for what CDI is trying to accomplish. Lastly, having physician buy-in and cooperation can make or break the success of implementing CDI. 

Here is a diagram that illustrates the CDI functions depending on the outpatient setting. 

Physician Practice
  • Ensure the capture of all diagnosis that the provider is currently assessing, treating, or monitoring
  • Verify the E&M code assignment for the encounter is correct based upon the available documentation
  • Identify opportunities for remediation of the EHR software to improve the provider workflow in support of efficiency and clarity of documentation
  • Ensure complete documentation of diagnoses that impact the HCC assignment and the associate risk adjustment factor
Emergency Room
  • Capture the severity of clinical picture
  • Accurately capture facility ED level charges
  • Improved documentation of infusions and injections
  • Creation of an accurate problem list
  • Addressing and correcting gaps in the patient care during visit
  • Acquire documentation of circumstances of an injury
  • Obtain clear documentation for reason to admit from ED
Infusion Clinics
  • Obtain capture of documentation of the following:
    • Order for services
    • Type of infusion
    • Infusion route and site
    • Stop and start times
    • Consistent documentation of nursing and physician
  • Educate nursing and ancillary staff on requirements for accurately documenting all necessary elements to support payment of infusions and injections
Diagnostic Clinics
  • Clarify documentation requirements for diagnostic versus screening services
  • Assist in educating provider on difference of diagnostic and screening testing
  • Encourage providers to document the specifics of their findings
Ambulatory Surgical Clinics
  • Review documentation to ensure medical necessity for outpatient procedures is clearly documented and meets NCD and LCD requirements
  • Assist with initiatives related to bundled payments
  • Capture documentation of risk adjustment during pre-admit testing and primary care referral
  • Confirm proper documentation after discharge to ensure proper post-acute transfer
Wound Care Clinics
  • Validate documentation of the following:
    •  Diagnosis of wound
    • Location and laterality of wound
    • Wound type
    • Cause of wound



Arrowood, D., Johnson, L., & Wieczorek, M. (2015, July). Clinical documentation improvement in the outpatient setting. Journal of AHIMA, 86(7), 52-54. Retrieved from http://bok.ahima.org/doc?oid=107688#.WRjwfOXyvIU

Combs, T. (2016, May). Benefits and barriers for outpatient CDI programs. Journal of AHIMA. Retrieved from http://journal.ahima.org/2016/05/27/benefits-and-barriers-for-outpatient-cdi-programs

Outpatient clinical documentation improvement (CDI): An introduction. (2016, May). Association of Clinical Documentation Improvement Specialists. Retrieved from https://acdis.org/system/files/resources/outpatient-cdi-intro.pdf

Vir, R. (2016, August). Four reasons why hospitals have to start outpatient CDI programs now. Retrieved from http://www.saince.com/four-reasons-why-hospitals-have-to-start-an-outpatient-cdi-programs-now/


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