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Discussions and initiatives surrounding outpatient clinical documentation improvement (CDI) have been infiltrating the healthcare industry for several years. Developed in response to the Centers for Medicare and Medicaid Services (CMS) Diagnostic Related Group (DRG) system, the program gained heightened traction around 2007. With the implementation of advanced technology; electronic health records (EHR); and coding for compliance, accuracy, and completeness, outpatient CDI is essential to your health organization’s proper operation and overall patient satisfaction.
How is the quality of outpatient CDI defined?
The quality of outpatient clinical documentation is based on patient safety, medical education, medico-legal issues, and justification of reimbursement, according to one study published by BMC Health Services Research in 2012. While this study is now dated, it was presented at a time when health systems and physician practices were beginning to go digital, introducing electronic health records or EHR into the mix of routine patient care and documentation protocols.
This transition to electronic records offered a unique opportunity for many health systems to improve the quality of clinical documentation. EHRs presented a superior option to paper charts by allowing for more extensive or complete patient medical recordkeeping. The study also found that, compared to handwritten physician notes, EHR documentation was:
- “More understandable (89.2% v. 69.6%)
- More legible (100% v. 64.3%)
- More likely to have at least one diagnosis recorded (48.2% v. 33.2%)
- More likely to document that anticipatory advice was given (23.75% v. 10.7%)
- More likely to document specialty referral (77.4% v. 59.5%)
- More likely to specify drug dose (86.6% v. 66.2%)»
However, EHRs presented new challenges, such as redundant information, lengthier notes, and poor organization of information. Therefore, it’s important to have an outpatient CDI program led by a team of experts with knowledge of electronic recordkeeping to ensure the quality of documentation efforts remains intact — especially as technological advances continue and digitization and automation of documentation evolves.
Why is health and patient medical record documentation so important?
ACDIS interviewed Chinwe Anyika, Ph.D., RN-BC, CDIP, CCS, CCDS, CCDS-O, CPHIMS, manager of CDI and data operations at Memorial Sloan Kettering Cancer Center in New York City, who answered several questions regarding outpatient CDI. When asked why CDI professionals review outpatient records and what the danger was in not doing so, Anyika responded:
«CDI professionals should review outpatient records because the capture of HCCs and chronic conditions is very important in painting a patient’s complete medical story. This leads to a complete medical record which is reflected in accurate provider/facility profiling and reimbursement. Providers are then able to bill for a more comprehensive and accurate level of service, preventing down-grading/underbilling of services provided. Failing to do this results in discrepancies in the patient’s record, under or overpayment for services, and this is not the position desired by any provider or facility.»
In other words, documentation helps to provide an accurate picture of patient care and services provided. As patients navigate various outpatient medical options to serve their overall health objectives, each provider must create a clear, comprehensive, and accurate picture of their care that the next provider can rely upon to guide further treatment.
It also serves as a legal document to support patient diagnoses and billing efforts determined by procedural codes. Essentially, CDI is important to ensure sufficient diagnostic records.
Patient medical records must:
- Contain sufficient documentation to identify the patient
- Support the diagnosis and justification of the treatment
- Document the course of treatment, results, and continuity of care
- Provide adequate detail for the next practitioner to deliver continuing care, determine patient conditions, and review diagnostic or therapeutic procedures performed in response to treatment
Accordingly, accurate and efficient documentation processes can facilitate the following:
- Claims processing
- Coding
- Billing and reimbursement
- Quality data
- Improved patient outcomes
Challenges of Health and Patient Medical Record Documentation
Some key challenges are involved in healthcare and patient medical record documentation, necessitating CDI programs to improve overall data quality and patient outcomes. These challenges include:
- Unbundling codes
- Upcoding/undercoding
- Missing or incorrect modifiers
- Incorrect use of Modifier 22
- Time-based infusions
- Improper reporting of injections
- Reporting unlisted codes
- Lack of documentation of active Hierarchical Condition Classification (HCC) codes
- Use of unspecified diagnosis codes
In one survey, nearly 90% of those polled said they were unaware of or did not have an existing outpatient or physician services CDI program. Where outpatient CDI programs did not exist, the most significant barriers included:
- Insufficient resources (36%)
- Competing priorities (27%)
- Lack of staff expertise (25%)
Additionally, most respondents emphasized the need to provide administration with a profitable result corresponding to the initiation of an outpatient CDI program, such as a clear return on investment (nearly 30%) or «clearly defined focus areas for increased reimbursement» (about 16%).
Those willing to expand their CDI program to more effectively address outpatient and physician services (23%) within the next 6-12 months following the survey, provided their key objectives based on problem areas or challenges seen within their current documentation methodology.
The goal of over half (60%) of all participants was improving documentation accuracy. Fifty-one percent expressed a need to obtain documentation supporting the proper level of patient care (e.g., inpatient, outpatient, observation). Forty-five percent indicated a need to focus CDI efforts on reducing medical necessity edits and denials.
Implementing a CDI program may not change reimbursement, but it can enable a smoother process by addressing documentation issues upfront. For example, suppose documentation more accurately specifies patients’ level of care and bills accordingly. In that case, denials are less likely to occur, resulting in cost savings for your healthcare establishment across the board, including reduced staff.
Driving forces of facility outpatient CDI, such as emergency department visits, observation, same-day surgeries, and facility clinics (e.g., physical therapy, occupational therapy, and other ancillary services), include:
- Outpatient perspective payment system (OPPS)
- Payer specific requirements
- HEDIS/Quality measures
- Coding specificity
- Medical necessity (LCD/NCD)
- APC’s (Ambulatory Payment Classifications)
Driving forces of professional services outpatient CDI, such as clinic and office services, hospital visits (e.g., ED, OBV, IP), and surgical procedures, include:
- Value-based care
- Payer specific requirements
- Medical necessity (LCD/NCD)
- Coding specificity
- Risk Adjustments
- Hierarchical condition classification (HCC)
Risk Management: Where is improvement needed?
It’s important to involve physicians and key healthcare professionals on your team in the CDI process. Completing a quick analysis of your current outpatient documentation methods and identifying gaps within your existing approaches can help you better understand where you need to tweak the system.
Evaluate your recent performance and note various strengths and weaknesses within your documentation workflow. Maximize your strong points and acknowledge the areas where improvements are needed by establishing clear goals for your organization to tackle outpatient CDI adequately. Once you have clear objectives in place, you can better strategize how to achieve the desired results.
Review your organization’s outpatient records to identify opportunities where documentation could offer more clarity—remedying ambiguous data or gaps in your documentation, including missing or incomplete data. Questions you can ask yourself before you begin this process include:
- What record types will I be reviewing (e.g., facility, professional services, or both)?
- Will this be a prospective or retrospective review?
- What is the daily or monthly percentage of encounters to be reviewed?
- What are the specific payers?
Establish how you currently collaborate with providers, billers, and other healthcare team members to create documentation that accurately reflects clinical treatment, diagnosis, and interventions. Determine a process for encouraging cooperation, providing feedback, and completing physician education.
Lastly, discover what tools, software, or other resources, including current staff members or consultants, you presently have on hand to conduct thorough documentation reviews. What CDI software does your facility use for outpatient documentation handling? Do you need additional resources or manpower to carry out your short- or long-term plans for an effective and comprehensive CDI program?
Providing answers to these questions and completing a thorough documentation review can give you a good idea of your current pain points and what resources need to create an efficient outpatient CDI plan.
Benefits of Outpatient Clinical Documentation Improvement Efforts
Physicians and other medical professionals across private practices and public health systems agree that complete and accurate documentation is optimal to support effective operations. However, some health organizations and practitioners struggle to maintain consistent, quality documentation.
The overarching goal of a successful outpatient CDI program accomplished with the help and expertise of CDI specialists is to «educate physicians and other healthcare providers to enhance their documentation skills to the point where queries and audits are no longer needed,» according to a publication in the Online Research Journal: Perspectives in Health Information Management authored by physician advisors and clinical quality data analysts.
When CDI programs effectively address all problematic areas of documentation and make improvements where weaknesses are discovered, the outcomes are significant, benefitting both patient care and the overall function of the health care system, producing satisfied and better-served patients, and preserving a healthy bottom line for health organizations.
Facility outpatient CDI benefits include:
- Improved provider documentation
- Physician education and feedback
- Improved overall coding accuracy
- Reduced claim and medical necessity denials
- Identified missed charge opportunities
- Identified potentially overlooked comorbidities
- Enhanced patient clinical pictures
- Protection against clinical liabilities
- Improved patient care and clinical outcomes (HEDIS measures)
Physician professional services (pro-fee) outpatient CDI benefits include:
- Improved provider documentation
- Improved overall coding accuracy
- Verified optimal coding of the patient encounter, as reflected in documentation (E&M)
- Reduced medical necessity denials
- Identified opportunities for diagnosis specificity
- Captured HCCs and improved risk adjustment scores
Getting There: Partnering with Experts to Improve Healthcare Objectives Surrounding Outpatient Medical Documentation
When implementing an effective outpatient CDI program for your healthcare organization, it’s important to consider partnering with top-level CDI professionals with experience in the elements of high-quality clinical documentation, including clarity, consistency, completeness, reliability, legibility, precision, and timeliness.
Not only can experts in outpatient CDI carry out the financial goals of your health system by improving coding and billing, accounting for payment and risk adjustments, reducing denials, and augmenting reimbursements, but they can help ensure continuity of care for your patients, leading to improved outcomes and realized boosts in all areas of performance that assist to safeguard your public reputation.