Category: Outpatient CDI

The Crucial Role of Outpatient Clinical Documentation Improvement (CDI) in U.S. Healthcare

In the dynamic landscape of U.S. healthcare, the role of Outpatient Clinical Documentation Improvement (CDI) has emerged as a critical factor in ensuring accurate, comprehensive, and high-quality patient care. Traditionally associated with inpatient settings, CDI has evolved to address the unique challenges and opportunities presented by outpatient care, playing a pivotal role in optimizing healthcare outcomes.

Understanding Outpatient CDI:

Outpatient CDI focuses on improving the accuracy and completeness of clinical documentation in settings where patients receive care without being admitted to a hospital. Unlike inpatient CDI, which primarily concentrates on hospital stays, outpatient CDI extends its reach to ambulatory care, physician offices, and other non-hospital healthcare settings.

Key Contributions of Outpatient CDI:

Enhanced Quality of Care:
Outpatient CDI ensures that clinical documentation accurately reflects the patient’s health status and the care provided. This precision in documentation leads to improved care coordination, better-informed decision-making, and ultimately, enhanced patient outcomes.

Optimized Reimbursement:
Accurate documentation is closely tied to reimbursement in healthcare. Outpatient CDI specialists work to capture all relevant diagnoses and procedures, ensuring that healthcare providers receive appropriate reimbursement for the services rendered. This, in turn, contributes to the financial health of healthcare organizations.

Risk Adjustment Accuracy:
In the era of value-based care, risk adjustment is crucial for accurately assessing patient populations’ health status. Outpatient CDI plays a vital role in identifying and documenting chronic conditions and comorbidities, providing a more accurate picture of patient health and contributing to precise risk adjustment models.

Supporting Population Health Management:
Outpatient CDI contributes to comprehensive and accurate health records, facilitating effective population health management. By identifying and addressing gaps in documentation, healthcare providers can better understand the health needs of their patient populations, leading to more targeted preventive and management strategies.

Ensuring Compliance and Regulatory Adherence:
The healthcare industry is subject to numerous regulations and compliance standards. Outpatient CDI helps healthcare organizations adhere to these standards by ensuring that documentation meets regulatory requirements, reducing the risk of audits and penalties.

Challenges and Opportunities:

While the role of Outpatient CDI is pivotal, it comes with its set of challenges. The decentralized nature of outpatient care, diverse documentation practices, and varying EHR systems pose challenges. However, embracing technology, continuous education, and collaboration between CDI specialists and healthcare providers offer opportunities to overcome these hurdles.

The Future of Outpatient CDI:

As the U.S. healthcare industry continues to evolve, Outpatient CDI is expected to become increasingly integral to achieving healthcare excellence. Emphasizing preventive care, accurate risk adjustment, and seamless information exchange, Outpatient CDI is poised to contribute significantly to the industry’s ongoing transformation.

In conclusion, the role of Outpatient CDI in the U.S. healthcare industry is indispensable. By focusing on accurate documentation, improved reimbursement, and supporting population health initiatives, Outpatient CDI ensures that healthcare delivery is not only efficient and cost-effective but also patient-centered and outcomes-driven. As the healthcare landscape continues to evolve, the impact of Outpatient CDI is set to grow, shaping a future where precision and quality define patient care.

Hospital Outpatient Departments: Effective July 1, 2020 you must request prior authorization for certain hospital Outpatient Department (OPD) services

For dates of service beginning July 1, 2020, you must request prior authorization for the following hospital Outpatient Department (OPD) services:

  • Blepharoplasty
  • Botulinum toxin injections (when paired with specific procedure codes)
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

Medical necessity documentation requirements remain the same and hospital OPDs will receive a decision within 10 days.

While only the hospital OPD service requires prior authorization, CMS wants to remind other providers that perform services in the hospital OPD setting that claims related to/associated with these services will not be paid if the service requiring prior authorization is not eligible for payment. These related services include, but are not limited to, anesthesiology services, physician services, and facility services. Only associated services performed in the hospital OPD setting are affected. Depending on the timing of claim submission for any related services, claims may be automatically denied, reviewed, or denied on a postpayment basis.

For botulinum toxin injections, consult the list of codes that require prior authorization for more details. Generally, the use of botulinum toxin injection codes paired with procedure codes other than 64612 or 64615 will not require prior authorization under this program.

Saince announces the launch of tele-medicine feature within its clinical documentation solution

Doc-U-Scribe clinical documentation solution now comes integrated with tele-medicine workflow. Physicians and administrators can create tele-consultation sessions with patients seamlessly from within the application. This process eliminates the need for providers to use separate solutions – one for clinical documentation and another for video session.

The COVID-19 public health crisis has accelerated the use of tele-medicine solutions among healthcare provides across the nation. However, many small hospitals and physician offices do not have access to a single solution that takes care of all their needs. Physicians are forced to use multiple solutions to complete their tele-medicine workflow. They are often finding this process frustrating and cumbersome.

Doc-U-Scribe clinical documentation solution which is used by hundreds of hospitals and physician offices across the country provides an integrated and seamless workflow for clinical documentation as well as tele-medicine.   This new HIPAA compliant tele-medicine solution can cut costs, increase efficiency, and improve physician satisfaction significantly.

Saince announced that this new feature will be available to all their existing customers immediately. Saince also announced that with their plug and play model, any new hospital or physician office can be up and running with their tele-medicine program within 48 hours.

When Pursuing CDI, Using Risk Adjustment Is Vital

As healthcare has moved away from fee-for-service reimbursement models toward a more value-based system, the idea of using risk adjustment to account for individual patient risk and chronic conditions has become far more important for providers seeking to maximize quality of care.

In today’s healthcare environment, providers are often required to fight simultaneous battles on several fronts. For those pursuing clinical documentation improvement (CDI), they must balance sometimes-conflicting regulatory demands, workflow needs, etc. Further exacerbating the problem is the persistent shift of care provision to the ambulatory setting and the increasing demands it places on provider organizations.

As we have discussed in previous blog posts, outpatient CDI efforts face a number of unique challenges, such as decidedly larger case volumes than most inpatient settings and far shorter clinical visits. These shorter visits produce less usable patient data and offer a condensed window during which multiple team members must work in synchrony—accurately and efficiently—to gather that data. Outpatient providers must also go further, factoring in risk adjustment for each individual in their larger patient populations as well.

Often, problems with risk adjustment appear when inaccurate or incomplete diagnosis coding slips through the documentation workflow. For instance, failure to capture patients’ Hierarchical Condition Categories (HCCs)—and recapture year-over-year—can greatly skew risk scores for individual patients and potentially the overall population. Such mistakes can filter downstream to errors in patient care and increasing claim denials and, potentially, wreak havoc on pay-for-performance reimbursements.

This dynamic puts increased pressure on physicians to capture correct documentation at the point of care—getting it right the first time without a great deal of revision. Many have addressed the issue through Computer Assisted Physician Documentation (CAPD), which provides a number of CDI features. CAPD improves accuracy and lessens physicians’ burdensome workflow by precluding the need to rehash previously captured documentation.

The goal of these products is to allow physicians to complete patient care documentation faster and spend more time with their patients. Unfortunately, many traditional products, which were designed for inpatient settings, lack effective integration of risk adjustment. As a result, many providers are prevented from seeing the most accurate picture of the population they serve—and value-based care programs are not as successful as they could be.

To learn about PowerSpeak+RAPID – a CAPD platform combining powerful front-end medical speech recognition software (PowerSpeak) and Risk Adjusted Physician Documentation (RAPID) – contact Saincesaince inc logo

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.