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.
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:
Now that the smoke has cleared from the transition to ICD-10-CM/PCS, the healthcare industry is taking stock of how the transition changed the industry landscape.
In today’s shifting healthcare landscape, the evolving disciplines of HIM, clinical documentation improvement and healthcare informatics are merging. The recent implementation of ICD-10 offers additional opportunities to further specify the patient’s condition that enhances provider communication as well as accurate reimbursement. As risk base insurance models increase, many organizations are in the process of expanding their clinical documentation improvement efforts in order to drive optimized revenue and compliance.