Taking your first step in outpatient CDI
“Outpatient CDI isn’t just inpatient CDI in an emergency department or clinic,” wrote ACDIS Director Brian Murphy in an article regarding the 2019 ACDIS Symposium: Outpatient CDI in Austin, Texas. “It’s a different skillset, and it’s a different mindset.”
In it, Murphy explains how outpatient CDI professionals need to review patient charts pre-visit, postvisit, or in some cases “not at all, but spend their time educating networks of physicians dispersed throughout their organizations.” These specialists must understand Hierarchical Condition Categories, evaluation and management coding, and specific details of the Official Guidelines for Coding and Reporting, as well as have a complex understanding of chronic disease processes and how to manage problem lists.
Defying the daunting
“Implementing an outpatient CDI program can be daunting,” says Judy Moreau, RN, MBA, vice president of mid-revenue cycle at Trinity Health, and Andrea Eastwood, RHIA, BAS, director of clinical encounter and documentation excellence at Trinity Health, who presented together at the Symposium.
A few hospitals in the Trinity Health network began implementing outpatient CDI in July 2018. For the first phase of implementation, “we had our hospitals identify one or two departments where there might be an opportunity for outpatient CDI,” says Moreau, such as observation or the emergency department.
“We chose a nonprescriptive approach because we felt it was more helpful for them to pick their own departments where they thought they might have extra resources to give the support that starting an outpatient CDI program would require.”
The hospitals also needed to provide a thorough outline for how they were going to roll out implementation within the fiscal year. Unsurprisingly, some sites had trouble getting started, so Moreau and her team created a playbook for them.
“With inpatient, everyone knows what you’re supposed to be looking for. But outpatient, everyone has [slightly] different needs, and metrics could look different from hospital to hospital,” Moreau notes. A major hurdle with launching an outpatient CDI program is that because the avenue is still so new, it is difficult to set benchmarks.
The introduction to the Trinity playbook lists items to investigate in hopes of determining the areas that would benefit most from improved documentation, as well as an outline of the program’s roles and responsibilities.
After the introduction section, the playbook is structured in chapters for each of the outpatient review areas. Each chapter outlines the CDI scope for that department, a list of potential clinical and coding areas of focus to prioritize initiatives, guidance on collecting baseline data, and tips on how to estimate potential financial benefits.
“We also recommend outlining the key roles of everyone involved and listing specific skill sets needed,” says Eastwood.
Moreau and Eastwood agree on the importance of documenting practices and procedures throughout the rollout phases, too. In the playbook, each chapter contains a reminder to document both the workflow and the collaboration that occurs among the team.
“We will do huddles with the physician champion and document how long they are, what will be/was discussed, and all other important information,” says Eastwood.
The playbook chapters also contain sample documentation training tools, such as infusion start and stop times for an emergency room nurse. “They need to first know the importance of documentation in order to better collect it,” Eastwood says.
For their second phase, Trinity Health expanded to outpatient surgery centers and non-hospital-based services, such as urgent care and cardiology. “Look at areas [within the healthcare system] with high rejection rates or high bill-hold rates for potential opportunities as a starting point,” suggests Moreau.
Above all else, Moreau stresses to “always be looking at denials, because that always presents an opportunity.”
Documentation trouble spots
Lack of documentation can make the difference between receiving a denial or not. If a patient has multiple reasons for a visit, every condition should be thoroughly documented so it can be put on a claim.
Start and stop times for injections and infusions, while extremely important, are often forgotten. “Infusion and injection start and stop times must be documented, as there is always an area of opportunity here,” Moreau emphasizes. She adds that only 1% of the emergency department visits had an infusion chart before Trinity implemented their outpatient CDI program.
Start and stop times are also important for noting the hours a patient is in observation or recovery status. There is a high potential for missed opportunities with patients staying in observation for 36–48 hours, as these patients could meet inpatient criteria. Payers will not consider inpatient admission until the patient has passed the two-midnight mark, but changing a patient who passes that threshold from observation to inpatient can mean a drastic shift in reimbursement. Also note that, in order for the hospital to be reimbursed for observation, a patient needs to stay there for at least eight hours.
“Sometimes orders get missed to change the status of a patient, so the wrong status ends up getting billed,” Moreau says. Failing to convert observation status to inpatient status can negatively affect a facility’s reimbursement and lead to potential denials.
Moreau also suggests keeping up to date with the Medicare list of inpatient-only procedures, as sometimes there are outpatient surgeries performed that are on that inpatient list.
Additionally, educate physicians, regardless of setting, to document medical necessity. For example, consider joint replacements. “Medicare wants to see that a patient has failed other treatments before the joint replacement was performed,” Moreau says.
Outpatient CDI staffing
“It takes a multidisciplinary team to run a successful outpatient CDI program,” Moreau says. A successful outpatient CDI team is likely to consist of clinicians, charge-ofentry staff, auditors, outpatient coders, a chargemaster, denials coordinator, and CDI specialists.
Before launching the program, outline every team member’s roles and responsibilities. The team will need a leader to hold the group accountable and set goals for next year as well as to reevaluate what was done the previous year and find room for improvement. Much of implementing an outpatient CDI program is trial and error, so looking back on what worked well and making those changes in the upcoming year is imperative for growth and success, Moreau says.
The purpose for a multidisciplinary team is to have each member serve as a subject matter expert for their area of responsibility and expertise. Most of the individuals in the key roles have been performing their tasks or functions for a long time, and it’s important for team members to look at processes and challenges with a new set of eyes to invigorate collaboration, explains Moreau. Pioneering a new outpatient CDI program requires trying new things and will call for some professionals to step outside of their comfort zones.
“The first tool you need to get started is a basic data collection tool,” says Eastwood. A struggle many new outpatient CDI programs run into is collecting core data to prove the benefits of the program. Eastwood recommends starting with a homegrown tool such as a spreadsheet segmented into different financial classes, such as observation patients converted to inpatient or medical necessity denial volume. For each category, record the numbers for both Medicare and all payers within the fiscal year.
“Something we really looked at was inpatient statuses with one-day length of stay; maybe they should have been observation cases,” says Eastwood. This data will provide a starting point to compare before and after outpatient CDI implementation.
Eastwood also recommends providing the outpatient CDI team with a sample implementation plan. “This is an easy way for them to get their ideas down on paper,” she says. “It helps them communicate and articulate to us, but also they can start their plan of attack and outline initiatives within that specific area.”
A sample implementation plan can be as simple as a spreadsheet, much like the basic data collection tool Eastwood suggests. The spreadsheet can include information such as review area, initiative, people to involve, start date, and status. “What is important is giving your team a starting point,” she says. “Give them a guide to get going in the right direction.”
Finally, Eastwood and Moreau suggest using a fiscal year outpatient CDI implementation checklist; essentially, it provides a high-level outline of key activities that will get the outpatient CDI program up and running. This checklist will also allow capturing of specific financial data from the start, helping to prove return on investment (ROI) and financial benefits down the road.
Because of the prospective payment system used for reimbursing outpatient settings, nearly all outpatient CDI programs struggle to prove an ROI for their efforts. The ROI process happens slowly, and often it’s difficult to track where the financial gains are coming from.
“A major area that we found potential to prove financial benefits was with patients converted from observation status to inpatient status based on CDI work efforts,” says Eastwood. She suggests calculating the difference between the average observation reimbursement and the inpatient diagnosis- related group (DRG). Take the inpatient DRG reimbursement for the specific case where a patient was converted from observation to inpatient due to CDI’s efforts, subtract the average observation reimbursement, and the final answer is the case-specific CDI benefit. “Do not just give the dollar amount, but give the math behind it,” Eastwood suggests.
Eastwood also recommends tracking denial rates before and after implementation of the outpatient CDI program. “Determine the number of denials for a period of time and the associated lost revenue,” she says. “Track the number of denials reduced for a period of time after the outpatient CDI initiatives have been implemented.” You can then calculate the financial benefit related to denials by subtracting the dollar amount of the current denial period from that of the baseline denial period.
Eastwood and Moreau are working with the finance department at Trinity Health to develop enterprise outpatient CDI financial benefit tracking. So far, they have been able to set up tracking for query impact in observation and the emergency department using their CDI software.
As with any new CDI initiative, there are many possible starting points for outpatient CDI. Moreau and Eastwood, for their part, suggest looking for patients in observation who might be able to change to inpatient status. Additionally, start collecting baseline data and then adding the anticipated targeted financial benefits. “This allows the team to have a goal,” says Eastwood.
Track metrics such as query outcomes for observation, total CDI review rates, query rates, and query response rates. Providing tools to the team such as a playbook or sample documentation recording will also help by providing them with a launching point and goals to strive for.
Eastwood notes that some hospital sites are not fully embracing the tools they were given, as the learning curve is steep. “Outpatient CDI changes quickly,” she says. “But any work in outpatient CDI is better than no work. We know our tools might not be perfect, but at least it’s a starting point.”