Benefits and Barriers for Outpatient CDI Programs

By Tammy Combs

Many hospitals that have implemented clinical documentation improvement (CDI) programs have seen a reduction of claim denials and an improvement in appropriate reimbursement payments and accurate quality scores. For these reasons, CDI programs have become very popular in the inpatient setting and are now beginning to expand into the outpatient setting. There are two questions for CDI leaders to consider when deciding if CDI would be beneficial in the outpatient arena of their organization.

  1. What would the benefits be to the organization?
  2. What barriers need to be considered when developing an outpatient CDI program?

Even though the basics of high quality clinical documentation are the same in all areas of healthcare, the CDI program structure will differ between inpatient and outpatient areas. Let’s look a little deeper into some of the benefits and barriers facilities may encounter when making this transition.

Benefits of CDI

  • Accurate ICD Code Assignment: Specificity in diagnoses is just as important in the outpatient world as it is in the inpatient world. Each diagnosis should be documented to the highest level of specificity that is supported by the clinical evidence. This will impact hierarchical condition
    category (HCC) assignment, which will impact the risk adjustment factor (RAF) to accurately reflect the patient population cared for by a facility.
  • Accurate CPT Code Assignment: As with PCS codes in the inpatient setting, CPT codes capture procedural specificity in the outpatient setting. This is obtained through detailed procedure notes to ensure the correct procedure is reflected.
  • Accurate Ambulatory Payment Classification (APC) Assignment: APC is the outpatient prospective payment system applicable to hospitals. It is just as important that documentation supports the appropriate APC assignment in the outpatient setting as DRG assignment is in the inpatient setting.
  • Appropriate Reimbursement: High quality clinical documentation is just as important in the outpatient setting to receive appropriate reimbursement for the care provided.
  • Accurate Quality Scores: Just as inpatient is measured on various quality scores, so is outpatient. It is important that the documentation in the outpatient setting is of the same excellence to capture the correct quality scores.
  • Reduction in Claim Denials: Payment denials are seen in the outpatient environment just as they are in the inpatient world. Many times denials are a result of missing documentation to support medical necessity of the care provided.

Barriers to CDI

  • Staffing: Staffing for the outpatient CDI program will have challenges not seen in the inpatient program. There will be a reduction in the number of notes that will need to be reviewed since the patients are seen more quickly. The productivity standards and number of staff will need to be identified specifically for the outpatient program.
  • Timing: Inpatient CDI professionals will usually have several days to review documentation and query providers while the patient is still in-house. When reviewing in the outpatient setting, patients will be seen within a shorter time frame; a concurrent review may therefore not be possible. It will be crucial for programs to have a structure in place for the review to be performed soon after the visit but before the bill is completed.
  • Buy-In: Support of CDI programs through physician buy-in is crucial in all settings. The physicians are the ones who document and respond to queries. Without timely responses to queries, the program is at risk. Education will need to be provided to explain the importance of developing a CDI program in the outpatient setting.

Sharing knowledge is crucial for CDI programs, now it is time for you to share your thoughts and experiences on this subject. Do you work in an outpatient CDI program? Are you considering an expansion into the outpatient setting? Have you seen other benefits or barriers in the CDI outpatient programs that you can share with the readers?

Tammy Combs, RN, MSN, CDIP, CCS, CCDS, is director and lead nurse planner of HIM Practice Excellence for AHIMA. She provides professional practice expertise to AHIMA members, the media, and outside organizations on clinical documentation improvement (CDI) practice issues. Combs authors material and provides support for AHIMA’s online CDI education platforms. She also serves as faculty for the AHIMA CDI Academies and CDIP Exam Preps, and is a technical advisor for AHIMA on CDI publications.

Original source:
Combs, Tammy. "Benefits and Barriers for Outpatient CDI Programs" (Journal of AHIMA website), May 27, 2016.