CDI Is also Important in the Outpatient Setting

Independent physician practices can benefit from a clinical documentation improvement program.

Clinical documentation improvement (CDI) is not a new concept, but it’s gaining momentum. The impetus for this trend is a double-edged sword: The government continues to intensify its efforts to detect healthcare fraud and abuse and recoup improper payments to providers and facilities; and then, there’s ICD-10. The deadline for implementing the new diagnosis code set is less than a year away—Oct. 1, 2014; and this has forced many hospitals and provider-based practices to implement, or to beef up, their existing CDI program. Smaller, independent physician practices would do well to follow suit, as they, too, can benefit from having a program in place that supports the treatments and services they provide in the office or outpatient setting.

Help for CDI Implementation

The transition to ICD-10 is more than simply mapping and providing crosswalks, and it’s more than just identifying your office’s 25 or 50 most-assigned ICD-9-CM codes and translating them to ICD-10. Although these steps are significant, more focus should be directed to the documentation used to support those codes. And coders (and other healthcare professionals) should be more active in promoting CDI on behalf of physicians and other qualified healthcare providers. For example:

Begin retrospective audits of your providers’ documentation to examine whether all required information for coordination of care and billing support is captured. You can do this through random sampling of your most problematic documentation areas, as well as high-volume diagnoses and/or top service charges.

Establish a process for communicating any deficiencies found in reviewed documentation. This will more than likely require a query process in which the provider is asked for additional information in a non-leading manner. If your current electronic health record (EHR) is unable to send or receive electronic queries, use an inter-office HIPAA -compliant email system.

Devise a plan of action for education and training. Gather authoritative resources, such as the 1995 and 1997 Documentation Guidelines for Evaluation and Management (E/M) Services, ICD-9-CM and ICD-10-CM Official Guides for Coding and Reporting, Coding Clinic, etc., to support your final decisions. The Centers for Medicare & Medicaid Services (CMS) advises that you identify “documentation improvement opportunities that could impact multiple initiatives and not just focus on ICD-10.” Think of areas such as capturing pain scores for EHR meaningful use, proper electrocardiogram interpretation for the Physician Quality Reporting System initiative, or specificity in documenting chronic conditions, such as coronary artery disease, diabetes mellitus, and kidney disease, for hierarchical condition category (HCC) and diagnosis-related group (DRG) assignments.

Keep track of provider improvement (or lack thereof). Monitor the amount of queries being sent and what type of additional info is being requested. A CDI process will help you discover patterns—good and bad. Use this information to enhance or modify your education and training process.

AAPC reported on its website, “After thousands of ICD-10 assessments, we’ve noticed that only 37 percent of today’s documentation is ready for the transition.” Resources are available through AAPC to help you identify where your providers’ documentation stands now, and if it will support ICD-10 coding.

CDI Participants

Coders are integral to a CDI program, but you should also involve your physician(s) in the development process. For large practices with more than one physician, or for a practice employing mid-level providers, identify physician “trendsetters” or “champions” among your provider staff. These providers can be instrumental in promoting the importance of this program to those less willing to participate. You may also want to include case managers and other allied healthcare providers in the mix.

If your practice employs a CDI specialist, you’re one step ahead. CDI specialists are usually found in the inpatient setting, many of whom are registered nurses. To keep costs down in office and outpatient locations, consider enrolling a staff nurse interested in CDI in AAPC’s online medical coding program to attain his or her coding and auditing credentials.

Benefits of CDI

Implementing a CDI program in your practice will help ensure the correct and most accurate diagnosis codes are being assigned based on good documentation.

A successful CDI program will lead to:

  • Better communication with your provider
  • A decrease in claim denials/rejections
  • An increase in reimbursement (particularly in the area of HCC/risk adjustment coding and quality improvement programs)
  • Improved continuity of care and patient quality measures
  • A decrease in physician queries
  • An increase in coder productivity
  • Improved documentation

Hospitals and other inpatient facilities are beginning to reap the benefits and returns of CDI; many of your physicians have already been exposed to CDI by way of the patients they treat in the hospital setting. For some providers, this initiative will be a familiar process.

The Future of CDI

As our industry progresses toward meaningful, low-cost healthcare, it’s imperative for everyone to understand how these changes will affect him or her. Now is not the time to shy away from CDI, or to think it only applies to hospitals. Assigned diagnosis codes are directly linked to not only DRG reimbursement, but also to reimbursement-based programs in the office/outpatient setting. They affect physician scoring and identify severity of illness for any patient in any setting. And they directly affect healthcare policies, insurance coverage, and medical/technological advances.

Don’t wait until October 2014 to implement your CDI plan. Think about it now, get the right people in place, and begin the auditing and educating process.

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Bio: Leonta Julien-Williams, RHIT, CPC, CCS, has worked in the healthcare industry for the past 10 years. She has worked as a coder, auditor, and educator. Julien-Williams is the president of the Covington, Ga., local chapter.

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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