CDI Quick Tips: CDI Synergies with Risk Based and Fee for Service Models

CDI_QuickTips.pngWhat 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.

So what are the next steps to make this happen? Let me warn you…some critical thinking is required! Let’s not boil the ocean, so first we’ll start with HCCs. Stay tuned for more in future Blogs on MACRA & MIPS.

  • Identify a CDS champion with expert level coding and billing experience in the professional practice. The CDS working in this setting must have an in-depth understanding of professional fee billing and coding as well as clinical documentation best practice.
  • Select a small task force of physicians who have expressed concern over recent reimbursement changes related to HCCs. Recruit members by selling the potential reimbursement improvements for their practice!
  • Analyze HCC data for those physicians on the task force to identify gaps and areas to focus during the initial clinical record audit.
  • Conduct a focused audit to identify documentation issues such as lack of ICD-10 specificity to support medical necessity of treatments and services, diagnosis mismatch within the clinical record and lack of modifiers to ensure payment for procedures with multiple CPT codes.
  • Identify trends related to specific providers, service lines, treatments/procedures or unusual E/M code distribution compared to peers.
  • Investigate concrete solutions such as EHR (drop downs, templates, prompts), NLP and diagnosis prospecting applications.
  • Catch the costliest issues real time. Develop workflows to allow the CDS to collaborate with physicians concurrently.
  • Educate all practice stakeholders including physicians, PAs, NPs, nurses, medical assistants, and scribes
  • Monitor progress and develop risk mitigation plans for those issues not improving.

The improvements made in the physician practice clinical documentation process will spill over to the inpatient and outpatient settings. The changes occurring now in the reimbursement models due to risk based payers provides the perfect opportunity to reach out and gain physician partners in the CDI process.

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Topics: CDI