There is no doubt, attendees of last week’s ACDIS 2018 conference will be speaking about it for months to come. The conference was comprised of over 90 speakers including physicians, registered nurses, health information management (HIM) administrators, certified clinical documentation specialists (CDIS) and certified documentation improvement practitioners (CDMP) to name a few. The tracks included something for everyone: Clinical & Coding, Management & Leadership, Quality & Regulatory, Expansion & Innovation, Outpatient and Pediatric. Needless to say, the educational opportunities were vast and it would be nearly impossible to share them all.
However, one of the resounding trends that reoccurred throughout the conference is the importance of an Outpatient CDI (OP CDI) program. OP CDI has traditionally been focused in the clinic setting, specifically covering diagnosis for medical necessity. Some people call this “one & done”: clinic staff prompt the provider to document that one diagnosis to cover the work-up/testing being ordered and then they move on to the next patient. Now, the focus of OP CDI is shifting to risk adjustment and emergency department settings.
CDI in Risk Adjustment
HCC (hierarchical condition category) coding, if performed correctly, allows us to see the patient as a whole throughout the year. The HCC assignments coupled with the patient’s demographics equals their total risk adjustment factor (RAF) score. With advancements in electronic health records and interoperability, this provides us the ability to view patient data across the continuum making HCC coding feasible.
CMS defines risk adjustment as a statistical process and payment methodology based on the underlying health status of a patient and predictive healthcare costs in which disease burden determines the complexity of the patient.
Items to consider in your OP CDI program of HCCs in the physician office setting are:
- Reason for encounter
- Documentation of all conditions
- MEAT (monitoring, evaluation, assessment, treatment) criteria
- Risk adjustment (HCC) methodology
- Cumulative score
Keep in mind – costs are usually driven by chronic diseases.
CDI in the Emergency Room Setting
In the emergency room setting it is imperative we train providers to document the work they perform appropriately. Keep in mind, ED providers’ employment status can vary from independent group practice to hospital employee to contract management groups to resident physicians. Depending on the employment status of the provider, their allegiance to authority and willingness to alter their style will vary. Emergency providers are typically masters of uncertainty and overuse prepositions. The nature of their work lends itself to non-specific assessments, inability to do anything “after study” and inability to determine secondary diagnosis criteria prospectively. These items coupled with time and volume constraints and use of templates creates a haven for OP documentation improvement.
Here are some tips of what can work to make documentation improvements in your emergency department:
- Link documentation to E&M/CPT codes
- Help providers consider problems they’ve “fixed” as an active problem (acute respiratory failure requiring intubation)
- Relate CDI efforts to contract status
- Remember ER doctors think in short bursts and may resist details
- Identify a limited number of terms for use (high impact, high volume terms)
- Ensure references are easy to find and try not to make them look anything up
The Goal of CDI Is the Same
Don’t forget to utilize your inpatient CDI experience to create or enhance your Outpatient CDI program. After all, the goal is the same:
- Complete, consistent and accurate documentation
- Making sure diagnoses and procedures are reflected, supported and captured in the documentation
- Ensuring documentation reflects the diagnosis and procedure to the greatest level of specificity
Were you lucky enough to attend ACDIS 2018? I’d love to hear your insights on the conference. And share your tips for building or enhancing an OP CDI program in the Comments section below.