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.
- HCC for risk adjustment payment: Medicare Advantage Plans are focused on accurate HCC capture by facilities and professional practices. Where there are risk sharing bonus plans in place, accurate HCC capture affects not only the MA plan payment but also the provider practice payments
- Outpatient facility quality scores under CMS’s Hospital Outpatient Quality Reporting Program (OQR) – Outpatient CDSs can positively impact Quality scores by ensuring that clinical documentation supports the quality metric numerator and denominator and denominator exclusions
- Merit-based Incentive Payment System (MIPS) for the physician practice – Integration of CDSs into the query process within the professional practice can improve the MIPS capture rate and the specificity to ensure high quality clinical documentation that supports accurate quality score cards
- Denials management for both facility and professional practice claims. The outpatient CDI can impact the outpatient and professional practice denials in several areas:
- Medical necessity denials may occur because ICD-10-CM codes were not specific enough to support national or local coverage determination guidelines or to support the service provided. The outpatient CDS can work with the provider to ensure the necessary level of specificity to submit an accurate ICD-10-CM code and to reflect the medical need for the patient’s treatment.
- Coding accuracy – ICD-10-CM, CPT and HCPCS code errors can result in a denial because the clinical documentation does not support the code submitted on the claim.
- Time based unit accuracy – in the observation setting, the order time and date as well as the clinical documentation supporting the time of arrival and departure in the observation bed is essential to accurate claims submission.
- Charge capture in all outpatient settings – charge capture errors may occur because the charge entry EHR template or manual encounter form has an inaccurate description, staff/clinicians entering the charge information are not properly trained to select the correct code, and charge master, physician fee schedule and system interface crosswalk files may not be correct. These issues may be evaluated by the outpatient CDS and corrected through technology solutions, process redesign and staff/clinician education.
- Claims and coding edits: These edits include for ICD-10-CM, CPT, HCPCS, APC coding under the Medicare physician fee schedule (PFS) payment methodology and Outpatient Prospective Payment System (OPPS). Claims scrubber edits can delay claims processing. The outpatient CDI can monitor edit trends and resolve the issues causing the edits. Examples: Medically Unlikely Edits (MUE), CPT/HCPCS bundling issues, modifier gaps, comprehensive APC gaps, global period, frequency errors, etc.
Focusing just on HCCs would reduce the opportunity for improved reimbursement and quality scores in the outpatient and professional practice setting. The integration of an outpatient CDS into the clinical documentation workflow allows for concurrent monitoring of focused CDI gaps. The CDS can utilize pre, concurrent, post-encounter case review and provider queries to ensure that the clinical documentation is specific and accurate. The outpatient CDS can collaborate with providers and the coding team and provide education and insight into CDI best practices.