Symposium Spotlight: Outpatient clinical validation queries offer advanced CDI opportunities

CDI Blog - Volume 11, Issue 195

Rebecca “Ali” Williams,

Tara Bell, MSN,

Editor’s note: Tara Bell, MSN, RN, CCDS, CCM, manager of CDI and utilization review services for UASI based in Cincinnati, will present “Clinical Validation: Expanding Clinical Validation into Outpatient CDI,” on Day 2 of the ACDIS Symposium: Outpatient CDI. Rebecca “Ali” Williams, MSN, RN, CCDS, also contributed to this QA.  This year’s Symposium takes place November 8-9, at the Hilton Orlando Lake Buena Vista—Disney Springs area. To see the complete agenda, click here. To register, click here.

ACDIS: What do you think about the term “outpatient?” Are folks still confused about what it means to do outpatient CDI reviews?
Williams: I think it is a huge area of opportunity for the CDI profession. By expanding into the outpatient arena, we, as CDI specialists, help ensure the value of these record review efforts beyond the traditional inpatient setting. This is where healthcare is moving—treating patients in the most appropriate setting for the condition(s) at hand.

When you step back and look at how the inpatient CDI focus areas have expanded, those in the industry can really see how reviews look at so much more since the days of CC/MCC capture. We now are reviewing for patient safety indicators, hospital acquired conditions, and hierarchical condition categories (HCCs) even on the inpatient arena. We’ve come a long way.

Additionally, I think the industry is a little less confused by the definition of outpatient/ambulatory CDI and are now more attuned to nuanced needs of various outpatient settings. Programs are getting better at defining their focus within the outpatient setting, too. For example, in the physician office setting, programs typically focus on improving HCCs and risk adjustment factor (RAF) scores. I hear people now clearly stating that they are working on CDI in the emergency room or CDI in the outpatient surgery center instead of lumping those efforts under the vaguer terms of outpatient/ambulatory. So, I think we have made strides here.

Clinical validation outpatient scenario

A 66-year-old male seen in office for regular check-up, with notes indicating “DM Type 2-today’s exam consistent with no non-proliferative diabetic retinopathy in eyes. No DME. Patient has history of alcohol abuse and hypertension and most recently had an A1C of 8.1.”

The physician discussed importance of well-controlled glucose and blood pressure to prevent complications of diabetes in the eyes. A possible clinical validation query for this outpatient encounter aims to clarify the type of diabetes and the related potential hyperglycemia. Such a query might read:

Dear Doctor,

Patient in for recent office visit noted “consistent with no non-proliferative diabetic retinopathy in the eyes” and that there was a discussion related to the importance of “well-controlled glucose and blood pressure to prevent complications of diabetes in the eyes.” Please further clarify if the patient currently meets the clinical criteria for:

  • Diabetes Mellitus Type 2 with Mild Nonproliferative Diabetic Retinopathy without Macular Edema Hyperglycemia Bilateral
  • Diabetes Mellitus Type 2 with hyperglycemia
  • Other
  • Unable to further clarify

ACDIS: The clinical validation piece in outpatient, then, does it pertain to specifically to hospital-related outpatient services or is there something to be gleaned in this regard for the physician practice setting?
When CDI focuses on clinical validation, the accuracy obtained in the medical record then gets translated across the patient care continuum. This has broad implications across the spectrum and provides a holistic approach to CDI.

Physicians need to be more in tune to painting that accurate picture not only in the inpatient setting, but outpatient also. Capturing evaluation and management levels for physician billing is just as important when doing the head-to-toe exam and addressing all of the patient’s body systems. Doing so helps when fighting denials as well.

Bell: When thinking about outpatient CDI generally, or clinical validation reviews within the outpatient setting, people tend to see them as different entities, but really the process and the reasoning behind the reviews is very similar. I often say that the goal is the same, the language is the same, but in the outpatient world you might just be speaking a different dialect.

Williams: Remember the MEAT pneumonic—monitored, evaluated, assessed, treated—that essentially defines supportive information that should be included in the medical record to ensure the patient’s condition gets accurately captured? That’s really what we’re looking for in the physician practice setting. CDI professionals in this setting are going back and looking at the past year’s record and making sure those items that meet MEAT are captured. Such reviews may seem really difficult at the outset of CDI efforts, but a year or so into the program, the CDI staff have experience and can better identify new opportunities for improvement and diagnosis capture. After a year, it’s going to be like a well-oiled machine.

ACDIS: Can you tell us a little more about UASI’s outpatient efforts?
We’ve been focused on outpatient-related efforts since 2016 and now have a staff of seven, but are consistently growing.

ACDIS: What’s the trickiest part of making the transition from inpatient to outpatient CDI?
The focus really should be on the clinics, in my opinion. Once upon a time, CDI programs on the inpatient side used be a “nice to have” improvement team, but now they’re considered critical and have the full support of administration and even software and IT products behind the program. That’s where we are now in the outpatient/physician practice/clinic setting. Soon, CDI efforts there are going to be a necessary component of an accountable care organization of a healthcare system.

In terms of the actual reviews, I think the trickiest part is the speed of it, the difference in focusing on the HCCs, and not the in-depth review that we have always been used to on the inpatient side. It is just a different mindset and not hard. Anyone who can do inpatient reviews can do outpatient HCC reviews.

Bell: A strong clinical background, I feel, is key. The professional needs to be able to link the clinical indicators in the outpatient role as well. The transition from inpatient to outpatient CDI can be an easy one. I also feel the coding professional can mesh into this role with a strong clinical background. 

ACDIS: What types of metrics/data should program focus on in proving return on investment in outpatient efforts in general and related to clinical validation specifically?
Of course, you want to keep in mind many of the same measures that you do on the inpatient side and make sure you watch where those CDI queries result in positive improvements in the documentation.

Be careful, just as you would on the inpatient side, about productivity. The number of records a CDI staff member can review will depend on the type and focus of the review. Is the team conducting prospective, concurrent, retrospective reviews, or all three? Will there be an expectation of focused audits and reporting? How much physician education will the CDI team be conducting or will those educations session be carried out by a physician advisor or other member of the CDI team? In general, though, CDI productivity on the outpatient side is comparable to that on the inpatient side and one staff member can do roughly 75-100 records per week (about 15-25 reviews per day).

ACDIS: Fun question: Who is your favorite Winnie-the-Pooh character and why?
Winnie-the-Pooh, of course! How can you resist that sweet lovable bear? He loves and wants the best for everyone. We all need to be like him.

Bell: Eeyore would have to be my favorite because I have a puppy that acts just like him every time something happens he does not like. You gotta love him for expressing himself.