Guest Post: Expanding the CDI focus to the outpatient arena, part 1

Editor’s note: Crystal Stalter, CPC, CCS-P, CDIP, is the CDI manager for M*Modal in Pittsburgh. She has more than 30 years of experience in healthcare focused on coding, compliance, and physician documentation concerns. Contact her at crystal.stalter@mmodal.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article was previously published in Briefings on APCs and JustCoding. This is the first part of a two-part series. Please return to the blog next week to read the second part!

The focus for CDI specialists has historically been on the inpatient hospital stay. Reviews of the chart for conditions not fully documented and/or evidence of conditions not documented at all, has been standard practice.

However, with so many changes in the industry facing providers in their outpatient practices, the importance of CDI in places of service such as physician offices, ambulatory clinics, and urgent care clinics is even more vital.

The new Medicare Access and CHIP Reauthorization Act (MACRA) and Merit-based Incentive Payment System/Advanced Alternative Payment Model (MIPS/APM) regulations for physician practices emphasizes payments for quality over quantity. Various healthcare entities shifted their focus to hierarchical condition categories (HCC), with Medicare Advantage plans and other insurers offering risk-adjusted reimbursement for providers caring for patients with long-term chronic conditions. Finally, with the specificity requirements of ICD-10-CM, documentation needs to be even more robust to ensure correct capture of the most appropriate diagnosis code.

Providers are beginning to understand the importance of having a CDI specialist in their practice to ensure the documentation is appropriate to fulfill reporting for all these reasons.

While providers focus on the care of their patients, they also need awareness of what information needs to be in their encounter note to support reportable measure(s). With physicians seeing 50-plus patients a day in a clinic, that might be a lot to expect.

It’s not that providers can’t or don’t do a good job documenting the reason for the encounter, but identifying which additional piece of information may be necessary to capture a quality measure or an HCC is difficult. CDI specialists in that environment can review documentation and query the physician for additional information to support reportable diagnoses and measures.

From an HCC perspective, pre-encounter review of past visits can ensure documentation at the present encounter includes evidence of those chronic conditions for which the patient is continuing to receive care and treatment by that particular provider is recorded. From a quality measure perspective, the CDI specialist can ensure that the reportable measures chosen by that provider and practice are documented accordingly. Proper documentation of any diagnosis to its fullest specificity has direct impact on the choice of ICD-10-CM diagnosis code, most likely preventing denials for medical necessity causing less days in accounts receivable.