CDI Week 2019 Q&A: Outpatient CDI

As part of the ninth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Cherri Sanders, RHIT, a CDI specialist at Lourdes Medical Center in Pasco, Washington, and a member of the 2019 CDI Week Committee, answered these questions. Contact her at cherri.sanders@lourdesonline.org.

Q: According to the 2019 CDI Week Industry Survey results, more than 53% of respondents review outpatient records of some kind, which is more than double what it was in 2018 (19.08%). Does your CDI program include an outpatient program? Why was it the right time to implement an outpatient CDI program/begin conducting outpatient reviews?
A: We are a critical access hospital (CAH), so we get paid on a cost-based reimbursement model, not by DRG—so it made sense to focus on outpatient reviews before inpatient. When we launched the program, we were getting quite a few denials for outpatient claims.

Q: Which services do you review/not review? How did you decide which outpatient services to focus on?
A: We were able to abstract denial information based on data from our billing software. We took that information and drilled down to see what the top 10 denials were and then developed a work plan for documentation opportunities related to those diagnoses.

Q: People define the terms “outpatient” and “ambulatory” differently. How would you define those terms? Are they interchangeable in your opinion? If not, how do they differ?
A: I do not think they are interchangeable. To me, outpatient is any ancillary type of service, and ambulatory is any outpatient surgery type of service.

Q: What type of professional backgrounds do you employ as outpatient CDI specialists and why? What level of experience do they have and why?
A: For one of our hospitals, our CDI specialist is an RN, but at Lourdes, the CDI specialist has her CCS and CDIP.

Q: What’s been the biggest challenge with implementing an outpatient program?
A: Gaining buy-in from the administration was a challenge for us, but now that our chief financial officer sees the value in a CDI program, things are looking up.

Q: According to the Industry Survey, 14.85% of respondents review their outpatient records prospectively, 8.18% do so concurrently, and 14.85% do so retrospectively. When do your CDI specialists review outpatient records?
A: We review records retrospectively and then use our findings for provider education.

Q: What does the query process look like for your outpatient CDI reviews? Do you have a separate policy for these queries, or is it combined with the inpatient query policy?
A: Our policy is the same for both inpatient and outpatient queries.

Q: How has your outpatient CDI program dealt with physician engagement? What’s been the most successful approach?
A: We have a few physician champions who really helped open the doors for education and feedback.

Q: In your opinion, why should CDI professionals review outpatient records? What’s the danger in not doing so?
A: I think there is a danger in staying out of outpatient. By getting involved, you can avoid any medical necessity edits and potential denials on the back end. It just seems to be a much cleaner process than constantly fighting the denials after the claim’s been billed.

Q: For those looking to expand to outpatient reviews, what do you recommend as a first step?
A: Get access to your billing denial reports.