CDI Week 2021 Q&A: Ordering takeout (outpatient CDI)
As part of the eleventh annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Chinwe Anyika, PhD, RN-BC, CDIP, CCS, CCDS, CCDS-O, CPHIMS, manager of CDI and data operations at Memorial Sloan Kettering Cancer Center in New York City, answered these questions. She is a member of the ACDIS Leadership Council, the New Jersey/Delaware /Pennsylvania ACDIS local chapter and NJHIMA, and the 2021 ACDIS Furthering Education Committee. For questions about the committee or the Q&A, contact ACDIS Editor Carolyn Riel (firstname.lastname@example.org).
Q: Can you define what “outpatient CDI” means to you/your organization?
A: Outpatient CDI means the complete review of patients’ medical records in the ambulatory, emergency department, same-day, observation, or clinic setting to capture and support complete documentation of diagnoses, hierarchical condition categories (HCCs), medical necessity and chronic conditions. Query or clarification opportunities are identified, and providers are engaged to interact with the CDI specialists and document clearly, accurately, completely, and in a compliant manner.
Q: How is your outpatient program staffed? Do the same CDI specialists review both inpatient and outpatient records? If not, how often do inpatient and outpatient teams interact? How often does the outpatient team interact with coding/office management staff?
A: At my facility, the same CDI specialists review both inpatient and possible outpatient records. Currently, we review all inpatient records and emergency department records. We plan to roll out the other outpatient settings in the future. There is daily and constant interaction among the CDI specialists and coding team. We all have biweekly huddles to discuss and resolve any issue of mutual interest, the coders always notify the CDI specialists if anything requires their attention, and the CDI specialists interact closely with the coders during the reconciliation process. This helps foster a good working relationship because both departments must work in sync to achieve much needed results.
Q: Which services do you review/not review? How did you decide which outpatient services to review/not review?
A: Currently, we review only the emergency department records. For us, our emergency department is called the urgent care center (UCC), and most patients that present here get admitted or are observed for a time period. It is beneficial for the CDI specialists to start from the beginning of a patient’s presentation to determine and identify potential opportunities that may have existed but not documented when the patient finally gets admitted or goes into observation status. Chronic conditions, possible transient events, and HCCs may all be present during that time. A complete review of the record will help capture or clarify any of these.
Q: According to the 2021 CDI Week Industry Survey results, 24% of respondents either have a dedicated outpatient program or have inpatient CDI also reviewing some outpatient records—up from 2020 by roughly 4%. Do you think this data illustrates a notable trend? Should inpatient CDI programs be looking to expand to outpatient reviews in your opinion?
A: Yes, inpatient CDI programs should really expand to outpatient reviews. There are so many positive benefits to this, the major one being the ability to tell a complete patient story, the continuity of the patient record from a clinic visit through discharge. Chronic conditions, HCCs, acute events, and present on admission status would be captured at every level. Coding would be more precise and data collection/analysis can show a total picture of every patient.
Facilities lose a lot of metrics when they fail to realize that it is not just about gathering CCs or MCCs. Every facility can really get a good mortality index (observed/expected) when it focuses on capturing every applicable risk-adjusted diagnosis. Having both inpatient and outpatient CDI programs can bring all these together more completely for any facility. With a mortality index less than one, the expected mortality is way higher than observed mortality and the case mix index (CMI) becomes much improved. The interpretation? It basically means that your facility treats a much sicker population, can justify use of resources, and prove medical necessity. What else could be better than that for any facility? CDI is at the apex of better quality rankings and reimbursement.
Q: Another 22% of survey respondents said that they do not have an outpatient CDI program but plan to expand into outpatient in the future. What advice do you have for those looking to expand into outpatient reviews?
A: I would advise them to invest and make it happen. It is worth it. Return on investment will be immediate and long-lasting if it is done right. I say this because training, qualifications, and real experience matter in the CDI realm. Above all, constant training/education of CDI specialists goes a long way to determine how successful any program will be.
Q: Given that the number of respondents who are involved in outpatient CDI grew by about 4% since 2020, and those who said they were going to become involved in outpatient shrunk by about the same percentage, it can be assumed those who said in 2020 that they were going to expand actually did so by 2021. What are your thoughts on respondents’ ability to expand into outpatient during the difficult year with COVID-19?
A: It has been a difficult period for everyone due to COVID-19. I commend all those who were able to expand into outpatient CDI. A lot happened and there were more clinic visits. Telemedicine also flourished and grew, with good reason. Just this new area would have necessitated more accurate capture of documentation to justify medical necessity and billing.
Q: According to the survey, 33 % of respondents review their outpatient records prospectively, 16% do so concurrently, and 31% do so retrospectively. Just over 5% of respondents do not perform chart reviews, and instead focus on education. When do your CDI specialists review outpatient records? Why did you choose that timing? What are the benefits of reviewing records at these different times? In your opinion, what ways can an outpatient CDI program be beneficial by focusing on education instead of performing chart reviews?
A: In my facility, the CDI specialists review outpatient records concurrently and retrospectively due to the nature of the type of reviews we do currently. It is better to review concurrently so that documentation is captured and clarified in real time. For example, it is easier to clarify an exacerbation of chronic systolic congestive heart failure as it happens in real time and when it is fresh in the provider’s mind.
I would not advocate for a complete focus on education over chart reviews for an outpatient CDI program. A CDI specialist must review the chart, identify areas of documentation opportunity, and then customize the proposed education to the specific needs of the provider. Without this aspect, education will occur in a vacuum and will be too general. This is where we lose the provider’s attention because my experience has taught me that they don’t like being taught abstract concepts. Targeted chart review, performance data analysis, and focused provider education always do the trick of engaging each provider. Everything must happen in tandem to work well.
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? Is there a set policy governing those queries? What guidance/resources did you use to build that policy or procedure?
A: We use the same query process for both inpatient and outpatient reviews. The established components of a compliant query must be present in every query—the patient’s brief medical history, clinical indicators, treatment, and compliant response options. We do have policies governing the queries. We utilized the ACDIS/AHIMA “Guidelines for achieving a compliant query practice” and other researched documents from both associations to develop our CDI query policies and procedures.
Q: In your opinion, why should CDI professionals review outpatient records? What’s the danger in not doing so?
A: 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 over payment for services, and this is not the position desired by any provider or facility.