Article by Susan Richards Morgan, CCS, CPHQ, CPC, CDEO, CRC, CPMA, CEMC, CPC-I. This article was originally published on the A Journal of AHIMA Blog on April 25, 2018 and is republished here with permission.
Currently, most clinical documentation improvement (CDI) programs have been developed inside hospitals with an inpatient focus. Medicare generally expects an inpatient admission to need two or more midnights of medically necessary hospital care. For the CDI professional, this represents time to query and receive responses from providers—time that is simply unavailable in the outpatient setting. Because the actual patient encounter is compressed from days to hours (think emergency department) to minutes (outpatient clinics), timing of queries becomes a significant factor when structuring outpatient CDI programs. This article will discuss three different timing approaches that can be used in outpatient CDI programs with an emphasis on prospective reviews.
Timing approach one: Prospective Reviews
In prospective CDI, the goal is to help prepare a physician for upcoming patient encounters. In determining if prospective reviews are valuable for a physician practice, here are some points to consider:
- Outpatient prospective documentation reviews often involve a team approach and CDI professionals offer valuable expertise in developing effective and compliant review communication amongst care coordinators, coders, and providers. CDI professionals with both a clinical and coding background may be hard to come by in an outpatient setting and not all clinics have staff available to assist with prospective review. According to the researchers at the Robert Graham Center for Policy Studies in Family medicine and Primary Care, only 22 percent of solo practices and 35 percent of small practices have a care coordinator, compared with 63 percent of large practices. A 2017 Medscape survey reports an average of 1.5 medical biller/coders per physician practice. Medical billers are not the same as medical coders and only medical coders should review problem lists for coding accuracy. In 2015, only 18 percent of practices had full-time medical coders on staff. Many times, coding staff is centralized and will require additional coordination if undertaking a prospective coding review. Allocating staffing resources will be the first step in designing a prospective documentation review.
- Once an organization has CDI, clinical, or coding staff available to work in partnership with providers, the next step involves determining which patient populations to review. Value-based care contracts may incentivize providers to ensure patients receive preventative services and other quality metrics associated with medically complex conditions. Payers, such as Medicare, set aside resources for beneficiaries based on overall beneficiary healthcare status as documented by healthcare providers and reported through diagnosis coding. Providers who do not accurately portray the medical complexity of their patient panel may appear to over-utilize resources. It may be valuable to begin prospective chart reviews in Medicare patient populations with the goal of monitoring provider documentation for needed preventative services or other clinical quality metrics. Prospectively reviewing problem lists to ensure complete and accurate coding is also a worthwhile exercise in this population. A prospective chart review can also identify chronic conditions in need of increased specificity or a status update.
- Further stratification can be accomplished through selection of specific encounter types for review. Comprehensive preventative evaluation and management services are well suited for prospective review and clinicians appreciate being informed about needed preventative services. Comprehensive preventative encounters are often scheduled to accommodate increased clinical staff and provider time. Because of the additional time needed to complete or schedule all preventative services and update the status of all active conditions affecting the care and management of the patient, clinics often limit the number of comprehensive preventative encounters scheduled. Reserving prospective reviews for comprehensive preventative encounters can maximize the value of the review while deliberately keeping the number of reviews manageable.
Timing approach two: Concurrent Queries
In concurrent CDI, the goal is to clarify patient health status and the complexity of medical services prior to final reporting and claims submission. Concurrent queries often require a collaborative effort between clinical, coding, billing, and IT staff and involve system and process review that may take several weeks of discussion and development to execute. The end result may be improved templates or processes that trigger queries based on system edits that are implemented. Once again, the importance of developing a compliant query should not be overlooked; experienced CDI professionals are valuable in providing expertise in their construct.
Timing approach three: Retrospective Queries
The goal of retrospective documentation improvement is to explore previous documentation for patterns that may impact future documentation. Practices best able to implement a retrospective documentation review process are those able to pull and analyze data to identify denial trends. Denial review can be used to detect denial patterns related to missing or incomplete documentation. Organizations can then determine if a systems fix can be implemented or if provider education is needed. It is important to remember that retrospective education should not be tied to correcting finances, which would be more appropriately called an audit. Many entities perform regular random coding audits as well as audits to mitigate perceived risk. In an audit, if there is a finding, a financial adjustment may need to take place. Often, the only feedback outpatient providers receive regarding documentation comes in the form of audit results. CDI professionals undertake retrospective documentation reviews to analyze data trends and communicate more global opportunities that a random sample audit might detect. Clearly communicating how expected outcomes of retrospective documentation review differ from audits will help ensure success.
Consider Timing When Developing Outpatient Initiatives
Effective outpatient CDI programs strategically consider timing when developing outpatient initiatives. Targeting populations during specific encounter types can make a compliant prospective review process feasible in large outpatient populations with limited staff resources. CDI professionals can also help guide cross-functional teams in systems reviews designed to clarify and improve documentation during the mid-revenue cycle. Data trending is an effective method to recognize and illustrate provider education opportunities to clearly represent the complexity of medical services provided and to accurately characterize the health status of their patient panel.
Susan Richards Morgan is a coding operations manager with Duke University Health Systems Patient Revenue Management Organization.