Outpatient clinical documentation improvement (CDI) programs have moved into the mainstream, as hospitals and healthcare systems continue to embrace consulting companies’ push into the outpatient arena. As the CDI profession matures and the market for CDI consulting becomes more highly competitive and less lucrative, these companies have identified a new long-term revenue stream associated with consulting engagements, in addition to software. Like their counterpart inpatient CDI programs, outpatient CDI programs are primarily focused upon revenue capture – except in this instance, the focus is upon Hierarchical Condition Category (HCC) capture, as opposed to Complication and Comorbidity (CC) and Major CC (CC/MCC) capture.

Unfortunately, these outpatient programs are embarking down the wrong path, falling into the same misguided pattern that hospitals have travelled over the last 12 years, engaging in processes that fail to live up to the name in delivering “clinical documentation improvement” (or, more recently, “clinical documentation integrity.” Allow me to outline the fundamentals of outpatient CDI programs that ultimately will drive success in achieving sustainable improvement in the quality and completeness of physician documentation, from both a quality of care and financial performance perspective.

Mission of Outpatient CDI Programs
The mission of outpatient CDI programs must incorporate into the design of chart review processes the ability to achieve real, material improvement in physician documentation, centered around the physician. Just like inpatient CDI programs, outpatient CDI programs overlook, first and foremost, the physician, in the mainstream of program design. In both inpatient and outpatient CDI, the physician is often simply an afterthought, with the medical record serving as a reimbursement tool. The physician’s documentation is utilized to populate the record with ICD-10 diagnoses, translating into diagnoses driving revenue, as CFOs are led to think by CDI consulting companies.

With an emphasis upon diagnosis and reimbursement capture, actual energy, dedication, and commitment on the part of the CDI staffer in working with physicians directly to share best-practice standards and principles of documentation that best communicate the patient care provided takes a back seat. It simply is not one of their priorities, given the current Key Performance Indicator (KPI) metrics that promote “task-based” CDI query activities. Queries are not designed nor intended to change physician patterns of documentation, beyond transactional reactive introduction of diagnoses into the chart (that are often refuted by the payor).

The mission of CDI should be to facilitate clear, concise, consistent, contextually correct and consensus-driven documentation supportive of quality-focused, patient-centered, fully informed and coordinated care, all while clearly establishing medical necessity with optimal net patient revenue. Without clear establishment of medical necessity through complete and accurate physician documentation, with an accurate account of the patient’s need for care or services, the actual physician work performed – and how that work met and addressed the patient’s needs – there really is no need for CDI. To sum it up succinctly, without clear display of medical necessity, CDI is quite irrelevant. Capturing diagnoses is only one small piece of physician documentation that helps support, but does not determine, in and of itself, medical necessity.

Medical Necessity: The Fundamental Backbone of Outpatient CDI
Medical necessity is defined by 1862 (a)(1)(a) of the Social Security Act, Title XVIII 42 CFR, as follows:

  • “No payment may be made under Part A or Part B for any expenses incurred for items or services not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.”

Note: “malformed” (of a person or part of the body) is defined as abnormally formed; misshapen.

The Medicare Administrative Contractor (MAC) will determine if an item or service is “reasonable and necessary” under §1862(a) (1) (A) of the Act. Specifically, it qualifies if the service is:

  • Safe and effective;
  • Not experimental or investigational; and
  • Appropriate, including the duration and frequency, in terms of whether the service or item is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the beneficiary’s condition, or to improve the function of a malformed body member;
  • Furnished in a setting appropriate to the beneficiary’s medical needs and condition;
  • Ordered and furnished by qualified personnel; and
  • One that meets, but does not exceed, the beneficiary’s medical need

For any service reported to Medicare, it is expected that the medical documentation clearly demonstrates that the service meets all of the above criteria. All documentation must be maintained in the patient’s medical record and be available to a contractor upon request.

In the outpatient arena, HCC diagnoses are utilized in the computation of risk adjustment factor scores governing members’ per-month Medicare payments for Medicare Advantage plans. Diagnoses are captured and reported through the coding process, factoring in to the following year’s computational monthly capitation payments to Medicare Advantage plans.

What CFOs and the CDI profession are glaringly overlooking is that what really matters this year is hospitals and health systems generating much-needed net patient revenue, especially in these times of serious financial challenges providers face with the COVID-19 pandemic, postponement of elective surgeries, and overall decreased volumes and revenues resulting from declining ED visits and patients generally staying away from hospitals.  

Outpatient CDI: Saviors of Hospitals and Health Systems
The CDI profession can certainly play a vital role in serving as financial saviors for our employers, through a concerted effort toward achieving clinical documentation excellence. We can and must partner with physicians, incorporating a holistic approach to chart review that includes attainment of medical necessity through efforts at sharing best-practice standards and principles of documentation beyond HCC capture. Our goals as CDI professionals must be to clearly convey the care provided, including ordering of diagnostic workup and therapeutic services, which often are directed and performed in the hospital setting. Allow me to share current observations from recent physician office clinical documentation audits, wherein the facility had a mature outpatient CDI program in many physician practices.

In the process of carrying out hundreds of physician office encounter reviews from a clinical documentation improvement perspective, I noticed accurate HCC capture, with appropriate clinical specificity of diagnoses. On the other hand, I also noticed an overwhelming number of cases with ample opportunity for significant documentation improvement, on a wide array of fronts. The following is a representative sample of common documentation deficiencies in the record that detract from reporting of good quality care, accurate assignment of ICD-10 diagnoses other than HCCs, establishment of medical necessity for current office visit and ancillary services ordered by the physician, and lastly, accurate evaluation and management (E&M) assignment producing optimal reimbursement for the facility:

  • No chief complaint or incomplete complaint, i.e., “patient here in follow-up”
  • Insufficient history of present illness (HPI) germane to establishment of medical necessity for the patient encounter and optimal reimbursement; lack of a clear, complete telling of the patient story
  • HPI focusing upon past illness, rather than the present illness
  • No review of systems
  • No past, family, or social history
  • Incongruent and/or inconsistent physician documentation
  • Problem list not updated, containing contradictory information
  • Physical exam incongruent with the nature of presenting problem, as described and evidenced in the HPI
  • Overlooked diagnoses within the assessment not documented by the physician
  • Diagnoses included in the assessment that were not traceable to the reason for the patient encounter, as explained in the HPI
  • Plan of care not reasonable, nor rationale based upon clinical assessment, i.e., orders for services such as pain injections or advanced diagnostic imaging without a covered diagnosis or indication, which would generate an unnecessary, self-inflicted medical necessity denial on the hospital side

The Impetus for Outpatient CDI: A Wake-Up Call
Beginning July 1, Medicare will require prior authorization on five outpatient procedures, with tendency toward being cosmetic in nature. These five procedures are:

  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

Similar to when a professor in college indicated what sections of the book the student may wish to review in preparation for a test or final exam, Medicare, through the MAC, outlines  the documentation requirements and limitations of coverage to meet medical necessity in the prior authorization process. Now is the perfect time to transform current outpatient CDI initiatives to ensure performance and optimal outcomes of any program, to include achievement of complete and accurate physician documentation that is sustainable over time. It’s time to rethink current CDI processes, migrating away from pure focus upon reimbursement. Instead, focus upon the physician, and achievement of complete and accurate documentation that best communicates the care provided. Measure outcomes in terms of quality documentation supportive of medical necessity and optimal net patient revenue, as opposed to chasing HCCs like a dog chasing its tail. This has proven to be a lesson in futility in the inpatient arena, so why travel down the same path in the outpatient arena, expecting different outcomes?




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