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:
Mr. Jones, a 90-year-old grandfather, presented in the Emergency Department with his grandson to report disorientation, aphasia and lethargy after a fall at home. The patient also complained of pain in his shoulder. The ED physician ordered an MRI of the head and an x-ray of his shoulder. The tests were performed and the patient was placed in observation for 48 hours.
What was missed in the clinical documentation and coding process?
- Mr. Jones had an MRI of the head which was not covered with his diagnosis of delirium, lethargy and aphasia. Had the Emergency Department CDS queried the physician for additional specificity related to his admission diagnoses, further specificity of toxic encephalopathy due to an overdose of his prescription medication (valium) would have been documented. Toxic encephalopathy is a covered diagnosis in the Local Coverage Determination guidelines. Mr. Jones would not have been required to pay for the test out of pocket
- Mr. Jones also had a shoulder x-ray performed. A later external audit of the clinical record and corresponding claim revealed that the charge master description used during charge selection in the ED was incorrectly tied to CPT code 73020 (APC 551 payment $60.80). The payment was much lower for this CPT code than the 73040 Shoulder Arthrography with contrast (APC 5524 payment $351.71) that was actually performed.
- Ultimately, eight hours of Mr. Jones’ observation stay were denied because the order for observation services was documented much later than the patient’s admission to the observation unit.
- Dr. Scott, the patient’s attending physician did not document diabetes with peripheral angiopathy (HCC 18 Score 0.368) in his office record even though it was clearly stated in the emergency room record. This lack of coordination between the hospital and physician practice records resulted in an end of the year loss in reimbursement for Dr. Scott who only reported diabetes (HCC 19 Score 0.118).
The Value of an Outpatient CDS
Had there been adequate involvement by the Outpatient CDS and coder in this case, there would have been several different outcomes:
- Mr. Jones’s MRI of the head would have been covered. The CDS would query for further specificity and resulting diagnosis of toxic encephalopathy. The CDS would have monitored denial trends and noticed that MRI of the head was on the list of increasing denials due to lack of medical necessity and this procedure would be on the watch list.
- The CDS would have picked up the charge master description issue from the increasing write offs for the shoulder arthrography procedures.
- The CDS working in the ED would routinely check observation orders and timing of patients entering observation status to make sure the order was documented in a timely fashion.
- The coder in Dr. Scott’s practice would be on the lookout for chronic illnesses in the associated hospital record to ensure that all HCCs were identified for Dr. Scott.
No wonder so many hospitals are considering Outpatient CDI programs for 2017! Be sure to place this on your radar and reach out to himagine for a complimentary Outpatient CDI assessment.