With the current CDI trends shifting from inpatient to outpatient procedures, many facilities are focusing their efforts on Hierarchical Condition Codes (HCC's) as the move to value based care and risk adjustment models continues to evolve. If you are considering implementing an outpatient CDI program you must address gaps in multiple areas, not just HCC's, to optimize your approach. Here is a summary of areas that need to be addressed.
Journal of the American Health Information Management Association (JAHIMA) recently published a case study authored by myself and Karen Frosch, CCS, CCDS, CRC, CPHQ, CDI Project Manager at Christiana Care on their newly implemented Outpatient CDI program.
CMS has provided eligible clinicians with a relatively flexible process for engaging in MACRA in 2017. However, in 2018 practices will need to participate more fully in MIPS if they are not participating in an advanced APM. As an HIM leader, does your department have a clear strategy for assisting the affiliated physician groups within your facility or system? Perhaps you are even uncertain what HIM's role should be? Here are 3 key areas where you can contribute.
Most short term acute care providers have a formal inpatient Clinical Documentation Improvement (CDI) program in place as part of their overall coding process. Do you have insight on whether your program is optimally performing? There are 3 key areas I recommend you focus on to best answer that question.
What if you could improve collaboration with physician stakeholders and concurrently bring your inpatient CDI program to the next level? This is possible through the development of an outpatient CDI program that incorporates the physician practice under its umbrella. Physicians are now looking for resources to assist in the implementation of MACRA and MIPS as well and to improve their HCC scores and receive appropriate reimbursement from risk based payers. Those consultations with your physicians related to chronic and secondary diagnoses treated in their professional practice could lead to increased specificity of ICD-10 coding for DRG accuracy and decreased denials in both the outpatient and inpatient setting.
In looking toward 2017, hospitals are beginning to seriously consider expanding their CDI program to the outpatient and professional fee world. The increase in patients covered under risk based payment is one reason. The increasing denials due to medical necessity are another. Managing reimbursement in the outpatient setting requires a closer look at the specificity of diagnosis documentation as well as a clear picture of the patient’s diagnostic process, the practitioner’s clinical judgement and the patient’s treatment during the encounter. Let’s look at an example: