Tag: 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 to be impacted significantly by 2017 OPPS Final Rule from CMS

cms-announces-big-changes-in-payments-to-hospitalsCenter for Medicare & Medicaid Services (CMS) has released its Final Rule for Hospital Outpatient Prospective Payment System  OPPS) for CY2017 with significant implications to hospital outpatient departments.

Let me first give you the good news. For CY 2017, CMS is updating OPPS rates by 1.65 percent. The change is based on the projected hospital market basket increase of 2.7 percent minus both a 0.3 percentage point adjustment for multi-factor productivity (MFP) and a 0.75 percentage point adjustment required by law. After considering all other policy changes finalized under the OPPS, including estimated spending for pass-through payments, CMS estimates a 1.7 percent payment increase (before taking into account changes in volume and case mix) for hospitals paid under the OPPS in CY 2017.

Now a little background before the not so good news. Over the last few years hospitals have aggressively acquired physician practices and gained much with such acquisitions because the hospital OPPS rates were higher than MPFS of independent practices. There has been quite a bit frustration over this discrepancy resulting in a regulatory change by US Congress (SECTION 603 OF THE BIPARTISAN BUDGET ACT OF 2015 – aka Site Neutral Payments Provision) and now CMS is trying to fix this gap and equalize the playing field.

As required by the statute, the final rule with comment period provides that certain items and services furnished by certain off-campus Provider Based Departments (PBDs) shall not be considered covered outpatient department services for purposes of OPPS payment and shall instead be paid “under the applicable payment system” (which will be Medical Physician Fee Schedule (MPFS) beginning January 1, 2017. In order to make the transition convenient and to reduce the burden of the change, CMS has identified certain items and services are exceptions from this rule – meaning that these items and services can still be billed at the OPPS rates.

Physicians in PBDs furnishing non-excepted services will continue to be paid on the professional claim and will be paid at the facility rate under the MPFS consistent with current payment policies for physicians practicing in an institutional setting. However hospitals the payment rate for the technical component of the services will generally be 50 percent of the OPPS rate.

The second significant change is that CMS believes that a basic tenet of a prospective payment system is the packaging of all integral, ancillary, supportive, dependent, or adjunctive services into primary services. For CY 2017, CMS is finalizing policy refinements with respect to packaging. Packaging Based on Claim instead of Based on Date of Service. CMS is finalizing its proposal to align the packaging logic for all of the conditional packaging status indicators so that packaging would occur at the claim level (instead of based on the date of service) to promote consistency and ensure that items and services that are provided during a hospital stay that may span more than one day are packaged according to OPPS packaging policies.

Changes in Hospital Value Based Purchasing Program (VBP)

CMS received feedback that some stakeholders are concerned about the pain management dimension questions being used in the Hospital VBP Program, believing that the linkage of these particular questions to the Hospital VBP Program payment incentives creates pressure on hospital staff to prescribe more opioids in order to achieve higher scores on this dimension. Keeping this in view, in the CY 2017 OPPS/ASC final rule with comment period, CMS is finalizing its proposal to remove the pain management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for purposes of the Hospital VBP Program, beginning with the FY 2018 program year. CMS is also developing and field testing alternative questions related to provider communications and pain in order to remove any potential ambiguity in the HCAHPS survey.

Changes to Hospital Outpatient Quality Reporting Program (OQR)

The Hospital OQR Program is a quality reporting program for outpatient hospital services. The Hospital OQR Program requires hospital outpatient facilities to meet certain requirements, or receive a reduction of 2.0 percentage points in their annual payment update for failure to meet these requirements. In the CY 2017 OPPS/ASC final rule, CMS is finalizing the addition of seven measures to the Hospital OQR Program for the CY 2020 payment determination and subsequent years. CMS did not propose any changes to the CY 2018 and CY 2019 Hospital OQR Program measure sets, which include 26 measures—25 required and one voluntary.

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

The ASCQR Program is a pay-for-reporting program that requires ambulatory surgical centers to meet certain requirements or receive a reduction of 2.0 percentage points in their annual payment update for failure to meet the requirements. In the CY 2017 CMS is finalizing the addition of seven measures to the ASCQR program measure set for the CY 2020 payment determination and subsequent years. CMS did not propose any changes to the CY 2018 and CY 2019 ASCQR Program measure sets, which include 12 measures—11 required and one voluntary.