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CDI Insights

Venturing Into Outpatient CDI

Preparing your program for takeoff.

Inpatient CDI programs have been around for quite some time. However, the closer alignment between quality and reimbursement has inspired many hospitals to look beyond inpatient and incorporate outpatient clinical settings as well. As discussed during the 2015 annual ACDIS conference, organizations are ready to venture into this new territory -- they just aren't sure how to do it.

This column provides insight into the challenges related to OP CDI, how hospitals can get the ball rolling, and where outpatient efforts to improve documentation may be headed in the future.

What are the biggest hurdles associated with launching an OP CDI program?

FEE: One big challenge is that the world of outpatient CDI is so vast. It is easy to become overwhelmed. Outpatient settings generate far more claims than inpatient facilities, so the sheer volume of documentation to review is significant. Imagine the volume of documentation generated by a 70-physician multi-specialty practice. A CDI program in this type of setting requires a unique approach on a much larger scale.

Depending upon the focus of outpatient CDI, it is sometimes harder to justify immediate return on investment (ROI).  If the initial focus is rectifying charge capture, then the rewards are rapidly apparent, but if the focus is defining the risk of a member within a patient population, this requires a methodical approach to impact multiple encounters.

BONNEY: Proving ROI is definitely easier on the inpatient side. However, with the future of quality-driven payment and Accountable Care Organizations, hospitals will shift focus to outpatient documentation. Organizations need to understand Hierarchical Condition Categories (HCCs) and their effects on payments.

SEE ALSO: Three Steps Towards Data Driven CDI

I agree with Dr. Fee that the volume of outpatient claims makes it difficult to get these programs going. Organizations just won't be able to hire enough CDI specialists to review claims manually. Technology, including automated reviews, will be an important component of success for OP CDI programs.

How do you suggest hospitals approach the topic of outpatient CDI?

FEE: First, consider the specific setting in which you'll deploy the outpatient CDI program. Many organizations begin with emergency medicine, focusing on severity, medical necessity and risk adjustment/HCCs. Ambulatory family practice and internal medicine groups are another recommended starting point, as these are the settings where patient risk is usually established.

At the same time, consider your goals for OP CDI. Are you hoping to improve documentation related to inpatient medical necessity? If so, consider focusing on the ED to measure initial documentation gaps and establish overall risk and severity of illness from the time the first responders intervene. Do you want to improve medical necessity documentation and financial accuracy in ASCs? If so, consider implementing CDI in the specialty clinics that tend to establish need and risk for these surgeries.

HCCs are important regardless of setting. To improve your HCC capture and risk adjustment factor (RAF) scores, be sure that physicians review and target all chronic and acute conditions during well-check exams. Also identify those patients who have low RAF scores to determine whether these scores are accurate or whether documentation is lacking.

BONNEY: I agree with Dr. Fee and would like to add that technologies such as natural language processing (NLP) help OP CDI specialists search for terminology that may suggest certain diagnoses or complications present, but not documented. With NLP, the CDI specialists become more like data analysts. For example, the rules within NLP technology review all diabetic patients for the day and flag any unspecified documentation or abnormal lab results. A worklist is created for the CDI specialist to review and alert the physician -- even via the EHR -- to collect specific information or order certain labs/tests.

Will it be easier or more difficult to obtain physician buy-in for outpatient CDI?

FEE: The method of deployment -- not necessarily the inpatient vs. outpatient designation -- is what generally drives physician buy-in. Physicians need to understand why documentation improvement is important and relevant to their daily work. Physicians will get more involved in CDI when CDI programs are able to perform data analytics for risk stratification. Couple that with evidence-based medicine to care for patients, and you'll get physicians' attention.

There is also an important regulatory change that could pique physicians' interest in outpatient CDI. The Merit-based Incentive Payment System (MIPS) will eventually replace the Sustainable Growth Rate (SGR). It unites the Physician Quality Reporting System (PQRS), EHR Incentive Program, and Value-Based Modifier (VBM).

Data collection for the MIPS begins in 2017, and physicians may start to see either financial bonuses or penalties based on the MIPS as early as 2019. By 2022, low-performing physicians could see as much as a 9% decrease in Medicare payments. Outpatient CDI programs may be a solution to offset this potential revenue loss.

BONNEY: I agree that it may be easier to engage patients in outpatient CDI; however, we still need to be able to provide insight in real time. This requires using software to retrospectively and concurrently run rules against patient information. Using technology in this way prevents organizations from having to hire dozens of CDI specialists for which there will never be an ROI.

As outpatient CDI grows, will we see specialists who focus solely on outpatient services?

FEE: As the CDI profession continues to mature, we'll likely see a career ladder in OP CDI. CC/MCC capture in the inpatient setting will be considered an entry level function. As specialists advance, they can move into quality and eventually outpatient settings. Also, aligning CDI specialists by medical specialty as part of a holistic team focused on improving outcomes among chronic care patient populations may also emerge within accountable care and quality-based reimbursement environments.

When do you think we'll start to see widespread adoption of outpatient CDI programs?

FEE: I expect to see a lot of growth in OP CDI next year as value-based reimbursement and shared hospital-physician savings continue to grow. All stakeholders -- facilities, health systems and payers -- are interested in outpatient CDI as a way to adjust and reduce risk. Outpatient CDI programs will also skyrocket in 2019 when MIPS penalties begin.

BONNEY: I'll defer to Dr. Fee on this. I agree that there is real interest in outpatient CDI -- it just needs to find its place so it can take off. 

James P. Fee is vice president of Huff DRG Review. He is board certified in Internal Medicine and Pediatrics and currently practices on a part time basis as a hospitalist in large academic referral center. He has extensive experience in hospital based medicine, DRG management, CDI education and process development. Dr. Fee currently serves as advisory board member for ACDIS. Steve Bonney is EVP, Business Development & Strategy, RecordsOne. He is an active member of AHIMA, ACDIS, HIMSS and WEDI.

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