Podcast recap: Improving outpatient documentation inside and outside hospital walls

by A.J. Plunkett

Four years ago, when Tami McMasters Gomez, MHL, BS-HIM, CCDS, CDIP, the director of coding and CDI services at the University of California Medical Center at Davis in Sacramento, was asked to review the hospital’s contractual agreement for its Medicare shared savings population for risk adjustment, she had no permanent staff and no outpatient CDI program in place.

Using an initial staff of contract workers and optimizing available technology, she was able to put together a program that now has permanent staff and proven cost savings for the hospital. During an episode of the ACDIS Podcast, McMasters shared how she put the program together and how she gathered data to demonstrate its value to the C-suite.

With the help of three contracted staff, McMasters Gomez said she started with an approach to capture the easiest information targeting patients with multiple visits to an outpatient setting with a Risk Adjustment Factor (RAF) score of less than one.

“We were able to do a quick kind of review and show the return on investment to leadership, to say, hey, if we were able to touch all of these patients, we could really see significant improvements in our HCC [hierarchical condition categories] capture and in our RAF score, and in return higher reimbursement for those more complicated risk adjusted patients,” said McMasters Gomez.

After the initial review, she then had to establish a workflow and build a team that could demonstrate what could be done.

McMasters Gomez said that flexibility in understanding that it might be harder to capture patient information from certain settings was key to their success. For example, patients seen in the emergency department were essentially new patients and providers might not have the patient knowledge or time to answer every query.

“If they’ve already done their documentation, and they’ve moved on, and our query comes, then retrospectively it’s a little harder to get them engaged. But if you can get them that query before they’ve actually completed their documentation, that’s the sweet spot for us,” she said.

Among other tips, McMasters Gomez also outlined some steps smaller organizations that may not have a full-fledged outpatient program can take to support documentation integrity across the continuum of care.

“There are things that you can do, I think, where coders can actually place queries on the chart if they are educated in the risk adjustment models, so you could use coders to do the work. In my program, I have kind of a hybrid approach. I have coders. I have someone who has a Master’s in social work who comes from a population health background. I have some nurses that are both RN and LPNs,” she said. “I think there are ways to be very strategic and deliberate about how you do the work.”

In addition to leveraging your coding staff, McMasters Gomez recommended those with limited resources examine their existing technological solutions to see what could be used to support documentation across outpatient settings.

“If you have an EHR, whether it’s Epic or Cerner, there are templates, smart lists, dot phrases, things that you can build into the record to prompt the provider to be more specific when documenting certain diagnoses. And so, those are options as well, that you could leverage as trying to improve that documentation integrity, in conjunction with maybe coders being your gatekeepers, to identify when you’re lacking that specificity and getting them to place a query on the chart, maybe creating a templated query that’s very compliant that they can use to do that work,” McMasters Gomez said.

Even if the coders don’t have the bandwidth to do that, “you could do a cost analysis with what it would cost to bring these people in to do the job, and what your staffing needs are and show a predictive analytics model about what you would bring to the table if you brought the staff in,” she said.

No matter how you choose to approach outpatient CDI, McMasters Gomez said that showing your data and the impact you could be making with adequate resources to the C-suite will go a long way. Providing leadership with metrics such as current HCC capture rate, current RAF score, and potentially low-hanging fruit opportunities can make a compelling argument.

“Then predict if you were able to just even improve that by 30%, maybe that’s just two FTEs, what that would look like. And then if you were to improve that by 40%, and that’s four FTEs, what that would look like,” she said. “There are things you can do to demonstrate to leadership, here’s what we’re leaving on the table, if we don’t invest in outpatient CDI.”

Editor’s note: This article is a recap of the October 12, 2022, episode of the ACDIS Podcast. Plunkett is an editor with ACDIS’ sister brand, DecisionHealth. To receive updates about new podcast episodes, subscribe to CDI Strategies today!