What’s the Hype?…Outpatient Clinical Documentation Integrity

In last week’s blog: Evaluation and Management (E/M) Essentials, we mentioned aligning coding educators with clinical build experts to support a foundation for accurate coding and charge capture success. Undoubtably, such an education and feedback program promotes a healthy dynamic between clinical and revenue cycle operations. How do we support operations to ensure the front-end (clinical) connects with the back-end (reimbursement and date capture)? As hospitals, clinics, and physician owned practices try to find innovative ways to adapt to the changing healthcare payment landscape, there continues to be focus on solutions to fill this gap. For years, Clinical Documentation Integrity (CDI) certainly has been on the forefront answering the call to bridge this chasm. Today I’d like to focus directly on Outpatient CDI concepts due to the high-volume impact such a program can have on an organization.

Outpatient CDI has emerged as a top priority due to broad opportunities for improving clinical quality and efficient coding/billing processes. The desired focus of Outpatient CDI should be designed to fit your organizational initiatives. Outlined below are a few vulnerable areas of interest:

• Medical necessity edits & denials
• High dollar/high-volume services
• Services on the Office of Inspector General’s (OIG) Work Plan
• Injections and infusions.
• Capturing of Hierarchical Condition Categories (HCC)
• E/M Services
• Surgical procedures with known documentation deficits

Polishing clinical documentation in these areas yields positive results leading to improved coding accuracy, cleaner claims and accurate reimbursement capture.

If you are developing or working to enhance your outpatient CDI program, here are several of our recommendations and tips:

Scope/Design:

• Establish accountability and skillset supporting the OP CDI program.
• Understand the organization’s clinical and revenue cycle collaboration.
• Develop a project objectives and goals.
• Define metrics to support transparency and accountability.

Analytics:

• Determine data aggregation and dissemination.
• Ensure systems support data collection.
• Prepare staff with necessary skill set and access to support.

Implementation/Education:

• Establish effective communication with clinical partners.
• Engage CDI Committee for approval of strategy and define opportunities
• Partner with IT clinical build teams.
• Ensure your CDI team is well-prepared.
• Utilize consistent education methodologies applied across specialties.

Monitoring:

• Ensure you create baselines to measure your success.
• Define a reporting cycle and timelines.
• Keep your metrics consistent and realistic.
• Reevaluate as measures are achieved or initiatives change.

Already created a successful Outpatient CDI program? Congratulations on a major initiative accomplished! If you need assistance retooling concepts or are in the beginning stages of program development, let The Wilshire Group share our experience providing realistic implementation strategies. Associations such as the Association of Clinical Documentation Improvement Specialists (ACDIS) and the American Health Information Management Association (AHIMA) also provide helpful guidance around these supporting concepts. An Outpatient Clinical Documentation Integrity program can be paramount to your organization’s outpatient clinical quality indicators, workflow efficiencies, cost containment, and overall revenue integrity. The Wilshire Group is here to help and wishes you much success implementing your program.