Clinical documentation improvement (CDI) programs have become commonplace in inpatient care in the past decade due to continual flux in reimbursement rules and increased scrutiny of claims by third-party payers. With expanding volumes at outpatient facilities as a result of a shift away from higher-cost acute care, payers are using audits and other tools to ensure physicians in offices and clinics are accurately capturing services provided. Another factor driving the migration of CDI is that hospitals are acquiring physician practices, so they fall under acute-care CDI programs.
A major impetus for this new scrutiny is the Merit-based Incentive Payment System (MIPS), which rolled three quality and value reporting programs into one points-based program. MIPS isn’t just about scores and reputation, however; it is a catalyst to transforming physician practices from pay-for-volume to value-based reimbursement.
In any care setting today, physician participation, buy-in and support for CDI are crucial. Some physicians view this as just one of the many hoops they must jump through to get paid. They shouldn’t. Although there is an opportunity for a positive financial return, CDI is about quality. Accurate and complete clinical documentation will not only validate the care that was provided but also improve communication among all providers caring for a patient.
Any good CDI program incorporates factors such as severity of illness, risk of mortality, and length of stay. Lack of complete documentation may alter mortality and morbidity case mix index scores, which influence both physician and hospital profiles. However, outpatient CDI programs have distinct challenges from inpatient CDI. Outpatient visits are significantly shorter, making a concurrent review impossible. Also, the volume of outpatient visits is significantly higher. The program structure should allow for review as soon after the visit as possible, but prior to claim submission.
These factors result in much less medical information gathered from each episode to identify areas of opportunity. It also most likely will not be feasible to review all outpatient services, so the encounters most prone to risk should be identified.
Every organization will not have the same plan; each plan must be right for the types of outpatient care provided. Often when getting started a CDI program may focus on particular departments or service lines. Operational assessments may help determine where to focus efforts, paying special attention to claims denials at care sites with large medical necessity, such as the emergency department, observation services, ambulatory clinics, physician practices and ambulatory surgery centers.
Physicians are at the heart of all successful CDI programs, as it is their clinical documentation that is needed; however, clinical and coding language do not always translate directly. CDI programs help bridge that gap by helping to identify areas where things are not clearly stated so coding is done to a high degree of specificity.
There is some prospective work that can be done in an outpatient CDI program, including chart reviews of medication lists and chronic conditions, to update records and help plan what should be addressed at the time of the encounter, but the bulk of outpatient CDI is done after the patient encounter.
Objectives of inpatient and outpatient CDI programs differ, but quality of documentation is the driving factor. An inpatient CDI program often focuses on case mix index and severity of illness metrics while an outpatient program more often focuses on reducing denials and resolving missing charges.
You must have a way to measure results, so performance metrics are required. There need to be tracking tools and consistency in the data to allow key performance indicators to be established and met. The program should be incorporated into the normal workflow so as not to become a burden on staff and physicians. How physicians use and documentation in an electronic health record can have a tremendous impact on CDI. Staffing determinations may be resource-driven, input-driven or ratio-driven, but there needs to be a way to measure the return on investment. Timely feedback should be available.
In the end, the best metrics on documentation are whether care is improving and appropriate reimbursement for services rendered is being achieved.