Q&A: How to get started in outpatient CDI
Q: Did your organization get formal training for outpatient CDI? If not, what was your source for education? Also, how did you choose the first providers to work with and what was the process of doing so? Lastly, how does query compliance work in the outpatient setting?
A: To answer your first question, education comes in many forms. Some departments take advantage of ACDIS and its educational opportunities and resources, such as using PROPEL CDI education and Boot Camps for their CDI staff or sending their team leads to the ACDIS conference each year and then training new hires internally. Some organizations hire trained outpatient CDI contractors to start the program and provide training. For others the learning is entirely independent, however, with a manager doing research on hierarchical condition category (HCC) coding and risk adjustment documentation and paying for each CDI specialist to have their own ICD-10-CM book and expecting them to learn how to use it. Either way, programs could have any combination of supervisors, leads, trainers, and auditors who cover both inpatient and outpatient CDI. Auditors performing second level reviews can also provide feedback and continuing education.
As for choosing providers to work with, one way programs can start is with a specific patient population, such as those enrolled in the Medicare Shared Savings population (MSSP), and then target the providers seeing that population in the ambulatory clinic setting. A pilot with the largest clinics in the health system can also work. To promote success, a department could go with a clinic that has a small number of providers who are available for education and are one of the highest risk areas. Primary care providers can be good to work with, as they are responsible for managing and documenting most of the population’s chronic conditions.
Many programs start by identifying low hanging fruit, such as patients that had multiple visits with a risk adjustment factor (RAF) score of less than one, and then giving focused education and training to providers who have opportunities to better document the acuity of the patients or have low HCC capture rates. Sometimes, patients are selected based on payer contracts with shared risk plans, or the highest volumes of visits and lives in Medicare Advantage (MA) contracts.
CDI departments are at times asked to do the leg work on deciding which providers to work with, though it can also be a decision made by or with administration. Programs can also outsource help from a vendor for pulling metrics to demonstrate opportunities on where to start.
As for querying in the outpatient setting, one common practice is to get access to the clinic’s scheduled visits and perform prospective reviews two to three days beforehand. This way the provider can see the query when they open the patient’s chart and can address things to document during the visit. Many CDI programs use an HCC application or vendor-supplied tool to fire a best-practice alert for the provider in real time when there are potential HCCs to document, with their queries added to that form.
Compliant queries should be the same on the outpatient side as inpatient, following the ACDIS/AHIMA “Guidelines for achieving a compliant query practice” brief, including MEAT (Monitoring, Evaluating, Assessing, and Treatment), and never leading the provider. Ongoing audits and tracking query logs help with these kinds of queries just as much as inpatient ones.
Editor’s Note: This question was answered by members of the ACDIS CDI Leadership Council.