Journal excerpt: Getting started in outpatient

Just because outpatient programs are gaining traction, creating an outpatient CDI program from the ground up has its own challenges. The path to starting such a department is often nonlinear, and CDI specialists launching an outpatient program will likely need to go back to the CDI basics to gain administrative buy-in.

“The clinical administration generally doesn’t understand who we are [as an outpatient CDI department] and what we do; they think we’re coders,” says Celena Massey, BSN, RN, CCM, ambulatory CDI specialist with Novant Health in Charlotte, North Carolina. “I start helping them understand by telling them the importance of the documentation and the connection between documentation and HCC [Hierarchical Conditional Category] codes.”

Communicating the importance of proper documentation is a major step in setting up a successful CDI program, and Massey suggests focusing these conversations not on reimbursement, but on reminding providers about the importance of telling the patient’s full story. “If the patient is sick, make sure you’re showing how sick they are. Remind providers that they want to paint the full picture of the patient’s health,” she says.

Once the importance of documentation has started turning the gears in people’s heads, many departments will have to demonstrate how they actually plan to implement and run the outpatient CDI program.

“If you have an inpatient model, start there and adapt what you can,” says says Susan Richards, CCS, CPC, CPMA, CPC-I, CEMC, CRC, CPHQ, former director of clinical documentation and risk adjustment, and former manager of Medicare risk adjustment with Humana in Raleigh, North Carolina. “But if you don’t, you’re going to have a lot of work. Look for [ACDIS/AHIMA practice] briefs, work with others in your organization to create a clinical indicator book for conditions to focus on and what strategies they’re going to use when doing chart reviews, and get any education that you can. Those are some good places to start.”

The program’s infancy is also the best point to decide how you’re going to track patients and what key performance indicators (KPI) you’ll track, Richards suggests; this way you’ll define a solid data set from the start and be able to track it over time.

“Ask questions such as how many patients are in your model. Are you just doing value-based care? Are you doing Medicare and Medicaid? Only at-risk people? Just diabetes? Decide those first and track those people,” she says. “Figure out how many people are in your tracking pool and figure out how you are going to set up that tracking.”

A couple other questions to consider are:

• Will you do comprehensive reviews or focus on one particular issue or review focus?
• Will you track physician response rates, agree rates, and disagreement rates?

“The biggest challenge with the outpatient side is that the patient may not be in the office for more than 15 minutes, so organizations should develop a strategy from the start to address the limited time the person is in the office,” Richards adds. “When a patient is hospitalized, it’s a different, robust situation and they’ve likely had a lot of testing. [On the outpatient side,] CDI professionals don’t always have that robust set of information you would on an inpatient side. Parsing out and leveraging data analytics can provide a clearer point of view and direct the focus.”

For example, a patient coming in for an acute visit without any complaints or for a follow-up appointment isn’t the type of encounter you’d likely want to focus your attention and resources on, Richards says. Instead, concentrate attention on encounters with high clinical value that would justify a comprehensive assessment from a provider, including annual wellness visits.

Additionally, Richards suggests leveraging pre-visit reviews to make the most of your CDI team’s time. If you can get pre-visit information prior to the patient’s outpatient appointment, the CDI specialist can look at that information ahead of time and do a more in-depth review, Richards suggests.

“The point of pre-reviews and looking at high clinical value encounters is that’s likely where a provider has the most information and time to address the patient,” she says. “Not only are you already looking at baseline information, but also the provider is more likely to appreciate that any interaction with CDI is relevant.”

Editor’s note: Read this full CDI Journal article here.