January 14, 2013

CDI Broadens Its Reach
By Mike Bassett
For The Record
Vol. 25 No. 1 P. 18

More healthcare organizations are looking to extend their clinical documentation improvement efforts to the outpatient side.

While many hospitals have been steadfast at developing and refining inpatient clinical documentation improvement (CDI) programs, the implementation of outpatient CDI initiatives seems to be an afterthought at times. However, there appears to be a shift in that line of thinking.

For example, at a session during the 2011 Association of Clinical Documentation Improvement Specialists annual conference, the question was posed about whether outpatient CDI was “the new frontier.” Presenter Caroline Rader, an associate director with Navigant Consulting’s healthcare practice, pointed out that the demand for outpatient CDI should increase as regulatory and payer scrutiny of outpatient services intensifies and the volume of those services grows.

The Reimbursement Factor
According to Wendy Whittington, MD, MMM, chief healthcare officer at Anthelio Healthcare Solutions, the need for some kind of CDI program in the outpatient setting has been clear over the past several years as hospitals saw their large operating margins shrink. “So they needed to ensure they were getting all the reimbursement they were entitled to,” she says. “A lot of hospitals weren’t getting reimbursed properly, but they weren’t putting a lot of effort into figuring it out—but they need every penny now.”

Hospitals have traditionally focused their CDI efforts on inpatient encounters because of the large dollar figures associated with some diagnosis-related groups (DRGs), says Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates.

On the other hand, outpatient clinical documentation has been more problematic, she says, even though increased outpatient auditing activity means it’s now “in the spotlight.” The sheer volume of outpatient services performed in hospitals, along with issues such as coding differences and the fact that nonphysician staff plays a key role in documentation, means “getting your hands around a CDI program is a real challenge.”

As a result, when it comes to outpatient CDI, hospitals should be looking where the money is and that means “medical necessity and local coverage determinations [LCDs],” Clark says, adding that many hospitals—particularly those featuring specialty care such as wound care or cancer treatment—”are looking at their LCDs and have proactively begun documentation in those to make sure those areas are being reimbursed.”

However, it’s not necessarily all about the money, according to Whittington. “The very same data that sets you up in the inpatient world to get a patient put into the correct DRG or in the outpatient world to get them the proper E/M [evaluation and management] code, is also the data that is the basis for quality reporting and other statistical reporting,” she says. “So if as a physician I’m a poor documenter, very often what goes out to the public about, for example, mortality stats on patient congestive heart failure, can be very misleading and downright wrong. It may not be that my stats are bad at all, but that I’m a crummy documenter.”

Kimberly Carr, RHIT, CCS, a manager at HRS Coding/Elevated, says CDI can have a significant impact on how patients select a physician. “My family is constantly calling me to ask me about particular doctors,” she says. “And if I’m not familiar with a physician, I’m out there on HealthGrades.com looking at their scores. When you’re traveling, you ask yourself would you rather stay in a three-star hotel or a five-star hotel. It’s the same with the physician taking care of your mom or dad: Do you want a three star or a five star? And documentation plays a big part in that, not only on the inpatient side, but the outpatient side as well.”

It adds up to physicians having more incentive to document properly. As Whittington points out, ask physicians to document specifically enough so coders can capture the necessary information for hospitals to receive appropriate reimbursement and the physicians will likely respond that they’re more concerned with doing the right thing for their patients vs. ensuring specific documentation.

“But with the push toward public and quality reporting, there’s more of a sense of personal gain in [proper documentation] for physicians,” she says. “And there is also the overall compelling reason that it really is in the best interests of the patient. If you are doing a good job documenting the care of a patient, it’s going to help the next doctor that’s taking care of that patient understand what’s going on.”

CDI Implementation
According to “The Implementation of an Outpatient Clinical Documentation Program,” a white paper written by Laurine Johnson, MS, RHIA, for Ingenix, the first step toward implementing a CDI program is to evaluate coding processes to determine whether any issues are documentation related.

Whittington agrees with such a strategy. “The first step should be to look at what’s currently going on in your hospital,” she says, adding that a good time for a hospital to consider setting up a CDI program is if it’s getting ready to implement an EHR.

“Put in an EHR without thinking about where a hospital is heading regarding clinical documentation and you may install something counter to what you’re trying to achieve,” Whittington says. “You may build in processes that don’t work for you in the CDI arena.”

The next phase involves staff and physician education, Johnson wrote. The principles of clinical documentation will be different for inpatient and outpatient, Whittington says, “so my advice is to remember that doctors have a lot on their plates and that you need to help them understand the overall principles, which should help them everywhere.”

Finally, Johnson says, a CDI program should include a monitoring phase that will allow a facility to evaluate the project’s successes and failures.

Once a decision is reached to institute outpatient CDI, how much time and staff should be allotted? According to Carr, much depends on the size and nature of the organization. “In a smaller facility with well-trained physicians, you might be able to wrap your hands around it,” she says. “In a bigger facility—especially if you have a very robust CDI inpatient program—you may want to consider focusing some of [that staff] on outpatient.”

One problem is that hospitals, particularly smaller ones, are under the gun financially, says Robert Gold, MD, CEO of DCBA, Inc. “Larger hospitals may be able to afford [outpatient CDI programs], but smaller hospitals won’t,” he notes.

Whittington points out that research suggests inpatient CDI programs pay for themselves. “When you consider what you’re paying most CDI specialists and consider what the differences in reimbursement are going to be based on the work they do, CDI more than pays for itself,” she says. “Outpatient is too new a world and I haven’t seen any studies out there, but I suspect that the same is true for outpatient.”

CDI by Specialty
Specialty-driven CDI programs “absolutely” make sense, Whittington says, pointing out that a physician working on documentation naturally will have questions about accurate wording to obtain proper reimbursement for the hospital. “It’s really going to help you to have an expert there to think through these problems,” she says. “And it can prevent you from having problems at the back end when you have a good CDI specialist working on things at the front end.”

For example, Carr says coders often will see patients admitted from outpatient surgery without the necessary supporting documentation. “You’ll wonder why a patient has been admitted,” she says. “Is it simply a matter of convenience because the patient lives 100 miles away or did the patient develop atrial fibrillation after surgery and the physician wants to monitor it? Having a CDI specialist in that area means you’ll have that documented properly, and the chart won’t be held up on the back end at a time when the physician won’t even remember why he admitted the patient. So having someone there to ask the question is important.”

Clark says many emergency departments assign someone the responsibility of making sure charts are complete. However, these individuals—nurses, HIM professionals, or clerical workers—are more focused with crossing the t’s and dotting the i’s. “No one is checking [the charts] from the standpoint of medical necessity,” she says, adding that most hospitals haven’t yet reached that level of analysis.

“Could they reach that level some day?” she asks. “Maybe, but hospitals are strapped financially … although they are beginning to see an advantage in some areas.”

In certain departments, some hospitals are using revenue cycle management specialists who understand coding, documentation, and billing, Clark says. “I like to call them revenue cycle specialists,” she says. “So is it considered clinical documentation improvement? Maybe.”

Documentation Errors and ICD-10
There are various common documentation errors, Clark says, including unsigned physician orders and incomplete support to what’s billed and coded. “When we do an audit, out of 150 charts, probably about 10% are physician documentation issues and about 10% are nursing,” she says. “It’s important to understand that it’s not all housed in one area; you need to be able to read the entire record and see all the pieces in order to bring it all together.”

Specificity is always a problem when it comes to physician documentation, says Alice Zentner, RHIA, director of auditing and education for coding compliance consultants at TrustHCS. “And you can’t really blame them [the physicians]. When they’re in school, they’re learning how to treat people and take care of illnesses and disease, so documentation is something that’s not a priority. But that validation has to be there if you want to be reimbursed,” she notes.

CDI programs should play a critical role in the eventual transition to ICD-10, Whittington says, particularly since providers are already looking for ways to increase documentation specificity. “That specificity is only going to increase when ICD-10 rolls around, and we won’t be able to use the same diagnoses we use today,” she says. “Instead, a diagnosis for otitis media might be something like left otitis media first onset nonsuppurative.”

The move to ICD-10 will increase the importance of having strong documentation on both the inpatient and outpatient sides, Whittington notes. Besides teaching physicians about increasing the specificity of their documentation, it also will be important to focus on updating and refreshing superbills, she adds.

When it comes to physicians producing more specific documentation, the sooner the better, Whittington says. “If I start documenting now in a way that works for ICD-10, my coder can still code it for ICD-9 but not the other way around,” she says. “So you may as well start to incorporate into your CDI programs little tips and tricks you can use to move into ICD-10. If you’re not accustomed to always documenting laterally with left or right otitis, work on it because you’re going to need it and once that becomes second nature, you can begin to add something to that and then something to that.”

“Now is the time to start working with physicians in the outpatient setting,” Carr says, adding that the unspecified codes that coders habitually use “won’t fly in ICD-10 because it’s going to group to lower weighted payments.”

For example, fractures will demand a lot more specificity in the emergency department. Coders will have to be more precise in identifying the site of the fracture, whether it’s displaced or nondisplaced and whether it’s left or right. “This will make a big difference with ICD-10 where it didn’t with ICD-9,” Carr notes.

— Mike Bassett is a freelance writer based in Holliston, Massachusetts.