Title

Title

Outpatient CDI: Who, What and Where in the Hospital Setting Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA Manager, HIM Consulting Services, UASI Tara Bell, MSN, RN, CCDS, CCM Manager, CDI & UR Services, UASI 2019 American Health Information Management Association 2019 American Health Information Management Association Objectives Recognize the necessary skill sets for OP CDI staff Assess the required clinical and coding knowledge needed

for OP CDI Determine the needed data analytics for assessing OP CDI needs 2019 American Health Information Management Association Why Outpatient CDI Pre-emptive defense against charge denials Creating a clean claim Reduced denials Presents distinct challenges from inpatient CDI Shorter LOS

Increased volume Concurrent review likely not an option Prospective review, and Retrospective review prior to billing 2019 American Health Information Management Association Why Outpatient CDI? A variety of opportunities exist regarding the review of provider documentation completed during an outpatient or provider encounter Multiple drivers pushing the implementation of outpatient CDI Medical necessity

Patient status Risk Adjustment (RA) and Hierarchical Condition Categories (HCCs) Coverage criteria to ensure appropriate reimbursement 2019 American Health Information Management Association Why Outpatient CDI? Implementation of outpatient CDI requires a thorough analysis of the needs of the organization Financials Underperforming outpatient areas Denials specific to outpatient areas

Patient status issues Medicare Advantage (MA) providers MA patient population risk adjustment scores Annual evaluation of RA data Establish priorities for implementation 2019 American Health Information Management Association Where is CDI? Hospital based services outside of the inpatient setting Emergency department services

Ambulatory surgery Observation services Home Health . . . And more 2019 American Health Information Management Association Emergency Department Services Fast-paced, high volume care setting with an extreme variety of patient conditions being treated Reporting includes both professional and facility level coding for services, procedures and medical supplies Patient transfers from the ED to observation and inpatient status

create opportunities for CDI facilitation of accurate and compliant documentation Also provides an opportunity to capture and maintain the clinical severity of illness from the initial entry point through to care in other settings 2019 American Health Information Management Association Ambulatory Surgery Free-standing facilities or hospital-based departments performing scheduled same day surgical procedures Key areas of documentation include: Pre-surgical H&P

Anesthesia evaluation Intra-operative notes Procedure/Operative notes Post-operative assessment and re-assessment CDI is necessary to support capturing the diagnostic statements for medical necessity along with complete medical history, and intra-operative or post-operative complications 2019 American Health Information Management Association Observation Services Providers may need additional time to assess the

patients symptoms response to treatments, or clinical evaluations of lab results to determine the appropriate discharge plan or decision for admission CDI professionals can help ensure the documentation clearly states the conditions the patient is being admitted for Facilitate the documentation bridge between the outpatient observation record and the admitting H&P 2019 American Health Information Management Association Home Health Care (HHC) HHCs are crucial within the continuum of healthcare providing such services as:

Wound care IV therapy Injections Therapy PT, OT, ST Outcome and Assessment Information Set (OASIS) tool used for documentation of HHC services CDI professionals assist in the capture of all data elements needed to complete the OASIS assessment Must be completed within five days of the start of HHC and other intervals 2019 American Health Information Management Association

. . . And More Interventional Cardiology/Radiology Radiation Oncology Physical Medicine services Broad array of patient care settings for outpatient services Evaluate which areas may provide the most significant opportunities for documentation improvement activities 2019 American Health Information Management Association Key Elements for Hospital-based

Outpatient CDI ICD-10-CM CPT and HCPCS coding Medical Necessity Risk Adjustment Hospital Outpatient Quality Reporting Program (OQR) Denials Management Charge Capture 2019 American Health Information Management Association Who is the Right Fit? Utilize the clinical and coding expertise of the CDI

profession to provide information regarding: Specificity of diagnoses Identifying procedures to be coded Identifying medical necessity issues for tests/procedures ordered Assisting with quality metrics and physician profiling Identifying chronic conditions that impact the severity profile of the patient 2019 American Health Information Management Association Who is the Right Fit? The outpatient CDI professional requires:

Strong outpatient regulatory and coding understanding Coding knowledge Coding and sequencing guidelines Reporting requirements, claims submission/correction High volume chart review 2019 American Health Information Management Association Who is the Right Fit? The outpatient CDI professional requires: Strong clinical knowledge background Recognize what constitutes monitoring/treatment of specific conditions

Credibility with providers Care coordination, disease management 2019 American Health Information Management Association Who is the Right Fit? The outpatient CDI professional can be: Coding professional with strong clinical knowledge base CDI professional with solid outpatient coding understanding

2019 American Health Information Management Association Who is the Right Fit? Clinical Documentation professional and/or Coding professional Less medical information to review Greater volume of cases Productivity and staffing may vary according to the outpatient setting Consider the unique needs related to each setting when determining staffing 2019 American Health Information Management Association

Who is the Right Fit? Clinical Documentation professional and/or Coding professional can be utilized dependent on outcome focus Pre-Hire assessment to determine knowledge base Screening questions during interview Credentials CRC Certified risk adjusted coder CDEO Certified documentation expert outpatient CCDS-O Certified Documentation Specialist-Outpatient 2019 American Health Information Management Association

Prospective Review Opportunities Chronic conditions needing annual documentation or more specificity Medical necessity review related to LCDs and NCDs 2019 American Health Information Management Association Retrospective Review Opportunities ED documentation review of testing to establish medical necessity Case review for Observation encounters

Verify correct sequencing of HCC diagnosis codes for billing Review for missing charges injections/infusions and lab tests Denials management 2019 American Health Information Management Association Data, Data, Data Organizations should gather data to develop a focus on key areas for improvement Metrics: Improved quality indicators that track

increased compliance with quality measures or improved financial outcomes Assists in identifying areas of opportunity 2019 American Health Information Management Association Data, Data, Data . . . Organizations unique needs in program design Volume of denials for medical necessity Outpatient surgery medical necessity denials Are you part of an ACO? Do providers participate in Medicare Advantage programs?

Do providers participate in any value-based payment programs? 2019 American Health Information Management Association Metrics Measure the impact of the clinical documentation specialist in: Identifying missed interventions or treatments Capture and provider documentation of time-based codes (infusions vs. push) CDI specialist metrics should include: Risk adjustment factor (RAF) impact of the clinical documentation review process Number of communications placed Type of communication clarifications placed

Rate of provider communication agreement Impact of identified procedures, interventions, missed charges or medications 2019 American Health Information Management Association Metrics General ambulatory CDI program metrics may include: Denial rate Financial impact of denial rate Gross increase in RAF scores

2019 American Health Information Management Association ROI Reduced inappropriate inpatient admissions Reduced time in Observation status Admit to inpatient status Discharge home Capture of missing Emergency Department bedside procedures Capture of patients chronic conditions Increased provider severity and risk profile Reduced bill-hold times due to missing documentation or missing charges

2019 American Health Information Management Association Best Practices Optimal staffing levels Various outpatient locations Various provider specialties Collaboration with providers, revenue cycle team Define and share goals and objectives Workflows supporting quality and financial goals Accountability 2019 American Health Information Management Association

References 6 Things to Know When Preparing to Implement Outpatient CDI; Health Information Technology; November 20, 2017; https:// www.beckershospitalreview.com/healthcare-information -technology/6-things-to-know-when-preparing-to-implem ent-outpatient-cdi-2.html 2008 Final Rule 42 CFR Parts 410, 411, 412 et al published on November 27, 2007 Outpatient Clinical Documentation Improvement (CDI): An Introduction; ACDIS whitepaper, May 2016 AHIMA Outpatient Clinical Documentation Improvement Toolkit

2019 American Health Information Management Association

Recently Viewed Presentations

  • Sciences, Education Physique Et Epistemologie

    Sciences, Education Physique Et Epistemologie

    » LAGACHE « Toute conduite motrice se manifeste par un comportement moteur, mais elle ne se réduit pas à celui-ci. Les données observables de ce comportement moteur sont en effet investies par un sens, le sens vécu de façon consciente...
  • Vanderbilt University Department of Biomedical Engineering

    Vanderbilt University Department of Biomedical Engineering

    Vanderbilt University Department of Biomedical Engineering Device for Quantification of Re-Innervation of a Laryngeal Muscle Advisor: Dr. David Zealear
  • Life After TAPE 2007Our Baldrige Journey to Excellence…..

    Life After TAPE 2007Our Baldrige Journey to Excellence…..

    The Best Baldrige Things "Every process is perfectly designed to get the results it gets" ADLI "Baldrige makes you look hard at your processes." LeTCI "I had never used benchmarking and doing so against Baldrigewinners gave us a great avenue...
  • Erosion by Glaciers

    Erosion by Glaciers

    What are 2 types of glaciers? Continental Glaciers Valley Glaciers Continental Glaciers Cover land or continents Spreads out over millions of square kilometers Covers 10% of Earth's land Found in Greenland and Antarctica Covered larger parts of Earth (Ice Ages)...
  • High Flying Fun Aerospace Stories and Activities Presented

    High Flying Fun Aerospace Stories and Activities Presented

    (Otherwise it acts like a rudder and the kite spins around in circles.) Punch a hole in the flap at E, about 1/3 down from the top point A. This hole can be reinforced with an additional piece of tape....
  • Chapter 4 Managing Inventory

    Chapter 4 Managing Inventory

    Transaction motive- Need to maintain inventories to facilitate smooth production and sales operation. Precautionary motive- To guard against the risk of unpredictable changes in demand and supply and other factors. Speculative motive- The decision to increase or reduce inventory level...
  • The Transformational Use of Information and Communication ...

    The Transformational Use of Information and Communication ...

    The WorldBank and the AfDB already have considerable ICT invest-ments in Africa. But, projectsare generallypiecemeal,rarelytransformational, and are only a drop in the ocean compared with what could be achieved. This project creates a . platform for change. ICT Investment. www.eTransform...
  • The Fundamentals of Communicative Language Teaching (CLT)

    The Fundamentals of Communicative Language Teaching (CLT)

    Jigsaw task: Mamma! What if you were trying to find long-lost family members and you had some pieces of information, but not many, to go on? Your instructor will give each student a card with information about an imaginary person...