Note from the ACDIS Director: Outpatient query guidance released

By Brian Murphy

Outpatient CDI is a different beast than CDI performed in the inpatient hospital setting. The volume of encounters is significantly higher, as is the speed of the visit and the turnover of patients. Trying use the same processes for clarifying documentation with physicians is doomed to failure.

So, how should CDI specialists clarify documentation in this new frontier? We now have an answer.

After many months of work, ACDIS is pleased to announce the publication of “Queries in outpatient CDI: Developing a compliant, effective process.” This is a position paper, written by a committee of 10 industry experts and reviewed and approved by the ACDIS Advisory Board, as well as additional external sources. It is ACDIS’ official stance on this issue.

Click here to download and read it for yourself.

“Queries in outpatient CDI: Developing a compliant, effective process” breaks new ground. It permits the use of prior medical records to query the physician (not to support code assignment). Many outpatient CDI departments review encounters prior to the arrival of the patient. The paper also encourages interventions by CDI to help physicians manage their problem lists.

“Queries in outpatient CDI: Developing a compliant, effective process” does not include department structure, suggested workflows, or ideas for getting started in outpatient CDI. Those articles are covered elsewhere on our website, and in the CDI Journal.

What it does provide is a tight focus on the query process in the outpatient setting. Regardless of the timing of the query, or who performs the CDI function, questions or clarifications to the physician cannot be directive or assumptive in nature. The process of CDI querying must remain compliant. This paper builds upon the joint ACDIS/AHIMA physician query practice brief Guidelines for Achieving a Compliant Query Practice.

This paper encourages physicians to briefly and succinctly document not only the most accurate and specific diagnosis (or diagnoses) under treatment, but also to provide clinical support and rationale behind that documentation. CDI specialists can and should assist physicians in this task by pulling forward prior treatments, medications, social history, etc. It also provides helpful clinical examples and the must-have elements in any query template.

Outpatient CDI—and frankly, all CDI efforts—need to make it easy on the physician. CDI specialists, as the critical link between coding and front-line clinical care, are the bridge in this process. It’s an important and difficult responsibility and we hope that this paper makes it a bit easier for all those involved in the profession.

“Queries in outpatient CDI: Developing a compliant, effective process” provides a real-world, practical document that you can use to build a compliant, ethical practice of documentation improvement in outpatient settings, be they hospital clinics or physician offices. We welcome your input and will be covering this paper during our ACDIS Membership Quarterly Conference Call of February 16.

Editor’s note: Murphy is the director of ACDIS. Contact him at bmurphy@acdis.org.