Guest Post: Expanding the CDI focus to the outpatient arena, part 2

Editor’s note: Crystal Stalter, CPC, CCS-P, CDIP, is the CDI manager for M*Modal in Pittsburgh. She has over 30 years of experience in the healthcare industry, with most of her focus on coding, compliance, and physician documentation. She has spent many of those years as a consultant, working with physicians and hospital HIM departments to improve their workflow processes and revenue cycles. 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 second part of a two-part series. To read the first part of this article, click here.

There are multiple outpatient places of service the CDI specialist can have an impact. One such place is the ED, where capture of ancillary services, start and stop times (as well as medications and dosages for injection/infusion coding), and evaluation and management (E/M) code (the codes assigned for physician reimbursement) levels often get missed or are incomplete, causing subsequent coding issues.

Admission criteria such as orders written and signed, authorizations, and documentation of medical necessity to meet inpatient requirements represent other focus areas where CDI specialists have influence. Documentation for observation status, also often falls short. Here recording the time of the order is required for correct code assignment.

CDI specialists need to also review of the medical record for additional services performed in the observation unit – e.g., injections/infusions, catheter placements, etc. Ensuring all orders are complete, dated, and signed is also important, as well as documentation of time off the unit for ancillary testing which has impact on that total billable observation time.

Outpatient surgery centers benefits from CDI efforts where, in addition to reviewing orders for completeness, the CDI specialists can ensure the complete documentation of procedures, medical necessity, screening versus diagnostic/surgical procedures, and identifying bundled services. CDI specialists in this setting can query surgeons in the event documentation does not support the procedure performed.

The provider office/clinic perhaps has the greatest need for an outpatient CDI specialist. As mentioned in my first post, Merit-based Incentive Payment System (MIPS) reporting beginning January 1, 2017, requires a renewed focus on documentation supporting reported quality measures, ensuring documentation of the patient’s improvement, and advancing care information. This is enough to keep CDI specialists busy on a full-time basis. However, HCC reporting, with documentation supportive of chronic conditions which are monitored, evaluated, assessed, and treated by the provider, is also a large undertaking. Add in specificity of documentation for appropriate ICD-10-CM diagnosis code assignment, as well as ensuring the providers appropriately document any ancillary procedures done in the office, and the list of duties for the CDI specialists in the provider office grows even longer.

Finally, in any of these settings, the role of the CDI specialist can take on an educational component. Educating providers on “why” their documentation requires additional information, supporting evidence, etc., is extremely important. Given the number of patients moving through these locations daily, the fewer queries that need to be sent to the providers, the better. Education plays a role in ensuring the physicians provide complete documentation from the onset, giving him or her back time to do what they really want to do—care for their patients.

Who is the outpatient CDI specialist?

But why invest in a CDI specialist(s) for outpatient settings when existing staff typically perform these duties?

In my opinion, titles in practices give way to expectations for performance, so it is important to give individuals task appropriate to their defined roles. Let me explain. If a coder currently performs chart review to identify specificity and accuracy, and does so in addition to code assignment responsibilities it could impede his or her workflow.  Similarly, if a nurse performs chart reviews to identify specificity as well as to provide basic care to a give patient and prepare the patient for the physician, those responsibilities affect not only workflow but trigger compliance concerns as well.

Giving an employee the title of CDI specialist sets clearly defined expectations related to a particular job function, paving the way for a different type of working relationship with the providers and creating a more robust understanding of the importance of the CDI role.

When considering hiring an outpatient CDI specialist, consider several factors such as whether to employ technology to assist in review prioritization.

No matter what type of outpatient reviews a facility decides to explore, first define the focus and set the scope of practice. Next, decide whether to hire from an existing staffing pool from outside the facility—either as a new hire or an outsourcing firm.

And be willing to adjust. If this is a new position for the organization, being able to change directions and redirect focus when something isn’t working well or efficiently is key to having a successful clinical documentation program in your office or facility.

At the end of the day, documentation is key to every facet of the healthcare continuum, from that first patient encounter of the day all the way through the end of the billing cycle, and beyond to risk-adjusted payments and quality care reimbursement. Ensuring that the documentation is complete, accurate and fully specified is the focus of the CDI specialist in any location.