There has been more buzz than ever about starting an ambulatory CDI (Clinical Documentation Improvement) program. First of all, let me begin with saying in some circles you’ll hear ambulatory CDI and in some outpatient CDI. Ultimately they refer to the same areas of the physician practice or clinic, the ED (emergency department), outpatient surgery, or even observation to name a few. When you think about it, observation patients may be in a bed for around 48 hours and not so ambulatory but for our benefit, we will use the terms outpatient and ambulatory CDI interchangeably. Providers are really struggling to decide; do I venture into this area, how do I go about it, and what do I need to focus on? Let’s spend a little time today discussing a few options.
If you are a coding professional, I am sure you can immediately identify some areas of concern within the outpatient arena. They could include problems with the type or depth of debridement for CPT (Current Procedural Terminology) code assignment, appropriate modifier usage to identify when a service is above and beyond the usual scope of a procedure like with modifier 59, or assignment of E&M (Evaluation and Management) levels, or documentation to support medical necessity, reason for the test, which has been a long-standing and problematic issue. These are certainly areas that have been thorns in our sides and always receive heightened focus when that dreaded audit internal or external such as OIG (Office of Inspector General) or MAC (Medicare Administrative Contractor) comes out of nowhere and coding or billing gets in the administrative hot seat. Suddenly this is about real big dollars and all eyes are on you or your department. Totally not fun, right? These are all areas that are potential low hanging fruit for CDI dependent on staff abilities (Wait…staffing is for another DOCBytes (smile)).
As quality is becoming of increased focus due to MACRA (Medicare The Medicare Access & Chip Reauthorization Act) and providers are taking on more risk by partnering (wanted or not) with CMS (Centers for Medicare and Medicaid Services) and other payers in more aggressive contract arrangements, understanding and reflecting the severity of the patient becomes more and more important. Remember the well in many cases help cover payments for the sick, each individual member should have dollars to cover their payment needs, and managing severity with good outcomes shows the quality and value of the provider. Understanding HCCs (Hierarchical Condition Categories) are an important part of this and is built into programs such as Medicare Advantage and many of the quality programs such as ACOs (Accountable Care Organizations), PQRS (Physician Quality Reporting System), and VBM (Value-Based Payment Modifier). As we move to participating in these initiatives, focusing on coding for HCCs may be a good place to start. In case you are not are aware, OUR PHYSICIANS ARE CODING in the clinic and this data is being reported for patients Risk Adjustment Factor (RAF) scores. In most cases, these claims sail right out the door. Tackling this area could benefit you for Physician Compare Reporting, future contract negotiations, and provider incentive payments for PQRS, VPM, and MACRA.
CDI SEE (Self-Evaluation)
This is all a lot to take in right? Well I would say take a breath and CDI SEE. Take a look at where you stand with some of the areas outlined above. Identify your band-width and what you have the ability to do fully and well. Utilize the info below to take some beginning steps and move forward to achieve Holistic Documentation!
Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA
CPT® by American Medical Association