Archive: 13 November 2018

4 Factors to Consider for Optimizing CDI Workflows and Reporting

In recent years, the evolution of healthcare regulations has driven care away from the inpatient setting, while simultaneously increasing administrative and clinical documentation burdens for providers. As a result, many healthcare organizations have started expanding their clinical documentation improvement (CDI) efforts to outpatient settings by finding opportunities for increased reimbursement, enhanced quality, and improved patient satisfaction. However, this process also brings with it new challenges, far different from those faced with inpatient CDI.

Among the most explicit challenges that organizations face when pursuing outpatient CDI efforts are larger case volumes and markedly shorter clinical visits, which in turn generate far less usable data per patient. Additionally, that data is often collected by multiple team members during a narrow window, increasing the opportunity for costly errors. This dynamic underscores the need for efficient workflows that enable accurate, timely and comprehensive documentation.


As organizations explore optimizing outpatient CDI efforts, here are four factors to consider:

  1. Timely collaboration is crucial. Outpatient CDI efforts require a higher level of physician engagement, as well as an increased emphasis on workflow efficiency to ensure that accurate documentation is produced concurrently with the provision of care.

Fostering collaboration between providers, coding and other administrative staff is vital to any CDI effort’s success. These team members must understand how their roles align in order to support, create and sustain a culture of operational efficacy.

  1. Improved quality, care, and reimbursement go hand-in-hand. Streamlining organizational compliance from the point of care to the submission of a claim allows outpatient clinics and physician groups to optimize efforts with diagnosis coding and Hierarchical Condition Category (HCC) capture. It also helps them improve the Physician Quality Reporting System (PQRS) and Group Practice Reporting Option (GPRO) scoring and reduce error-driven medical necessity denials for patients.
  1. It’s critical to analyze and agree on goals and targets. A central component of fostering collaboration and improving metrics is first understanding specific organizational needs and identifying areas that need the most improvement. By focusing on collaborative resources in these areas, outpatient CDI efforts can be organized to ensure desired outcomes.
  1. Every organization’s needs will be unique. Key areas of improvement will vary from one organization to the next. Operational needs—from staffing to education to technology—will likewise be unique.

Designing your organization’s outpatient CDI efforts is a significant undertaking. To learn more about PracticePerfect, a platform to help you address outpatient and ER CDI, contact Saince.

Better Outpatient CDI For Emergency Care, Wound Care and Total Knee Replacement

As care is increasingly delivered in an outpatient setting, it is critical that clinical documentation improvement (CDI) programs are developed to ensure compensation for care. “Clinical documentation is at the core of every patient encounter,” says the American Health Information Management Association (AHIMA). The association goes on to say that a meaningful documentation process must be accurate, timely and comprehensive of the services provided. The process should also engage physicians, so that they begin to associate documentation with a higher quality of care delivery rather than an interference in care delivery.

A recent presentation from the 90th Annual AHIMA conference showcased best practices for ensuring better outpatient CDI in the areas of emergency medicine, wound care and total knee replacement procedures. The presenters outlined these key practical considerations for documentation:

Emergency Room (ER)

Better ER documentation centers around four key questions:

  1. Does documentation support the most appropriate visit level?
  2. Does documentation support the billable services?
  3. Does documentation accurately report staff present for care provided?
  4. Does documentation accurately report the amount of time staff spends with critical patients?

When it comes to supporting the most appropriate visit level, what severity is being documented? 

  • Self-limited or minor
  • Low severity
  • Moderate severity
  • High severity, requires urgent evaluation by the physician but does not pose threat to life or physiologic function
  • High severity, poses an immediate significant threat to life or physiologic functions

Supporting documentation is required for all elements of an ER visit, whether that means documenting the need for extra resources to deal with an intoxicated and combative patient, or the documenting the presence of a nurse in the room during a pelvic exam. The timeframe of patient time with nurses is a key element in being able to bill for critical care, with a requirement that at least 30 minutes of critical care services are provided and documented.

Wound Care

When it comes to wound care delivered in an outpatient setting, it is important to have clear and consistent documentation. Here are the key elements needed in documentation: 

  • Describe the type of wound, location and size
  • Describe if the wound is a partial or full thickness wound
  • Describe stages of pressure ulcers
  • Describe depth of pressure ulcers
  • Any undermining/tunneling/sinus tract
  • Drainage, type, amount or odor
  • Various types of tissue in wound bed
  • Wound edges and surrounding tissue
  • Indicators of infection and pain
  • Document interventions for healing and conditions that would affect healing
  • Current topical treatment plan, response to treatment, modifications to plan, implementations of new orders, reasons for not changing treatment plan, referrals
  • Document any education given to patient and caregiver

Total Knee Replacement

With total knee replacement procedures, it is important to note in the documentation that the procedure is appropriately offered in an outpatient setting. In order for the procedure to be taken off of the inpatient-only (IPO) list, it must meet the following criteria, all of which should be documented: 

  • A low anesthesia risk
  • Few or no comorbidities
  • Family at home to support
  • Patient can tolerate rehab in an outpatient facility or at home
  • Physician expects the patient to need fewer than two nights of hospital care

For more information, contact Saince about PracticePerfect, a platform to help you address outpatient and ER CDI.