Q&A: Incorporating CDI efforts in the outpatient arena

Q: Do you recommend carving out time for outpatient [documentation] review, or dedicating someone to this role?

A: We actually carve out time for outpatient review. We started with two initiatives in our ED. One was injections/infusions and documentation for our RNs, and the other was medical necessity documentation. The way we built a case for injections/infusion was our outpatient ED coders audited 100% of records for two weeks. They gave us a loss in charge analysis—what we would have recouped in charges had the RNs documented appropriately—and then we extrapolated that out over a year.

With medical necessity, we worked with the patient accounts department. They had to write off charges for things like CTs, EKGs, BNPs, and  PT/INRs because there wasn’t a diagnosis or symptom to support the need for certain outpatient radiological tests and labs. Patient accounts tracked those charges that were being written off.

If you’re a newer program, [now may] not the time [to start outpatient record reviews]. But if you’re an established program and you have the manpower, definitely it’s a good time to expand into outpatient areas. Compliant documentation is a big deal with RAC and other regulatory agencies [who are] making sure you’re supporting all your treatments and clinical thought processes.

We have four total CDI [specialists], including myself. We’re all RHIAs. Two are scheduled to be down in the ED during the week, each for two-hour increments, on top of going up to the inpatient units. We then switch off every other week. That way if someone goes on vacation, everyone has coverage and knows the process. It also switches up your day a little bit. You get to see different things outside of your normal routine with the inpatient reviews.

Editor’s Note: The above Q&A was adapted from responses provided by Avery E. Trickey, RHIA, as part of the first annual Clinical Documentation Improvement Week celebrated in September. At the time of this article's original release, Trickey was the manager of the HIM department at Advocate BroMenn Medical Center in Normal, IL.