Note from the Associate Editorial Director: Need-to-know information for outpatient CDI expansion

By Melissa Varnavas

For roughly five years now, the CDI industry has toyed with various ideas about what constitutes an “outpatient” program and how to effectively take successful inpatient programs to the proverbial next level by expanding into “ambulatory” services. Over time, a consensus of sorts has arisen with the term “outpatient” providing a counterbalance to “inpatient” as an overarching phrase equating to any type of program reviewing records not principally reimbursed by Medicare’s Part A (hospital) funds. Outpatient CDI efforts include the ED, hospital-based outpatient services (i.e., radiology, laboratory, etc.), ambulatory surgical centers, and physician practices, to name a few.

A 2017 ACDIS poll showed approximately 10% of hospitals possessed an outpatient (defined as hospital ambulatory or physician services at the time) CDI program with 24% of respondents indicating at the time that they plan to cover outpatient and/or physician services in the next 6–12 months. Nevertheless, preliminary results from the 2019 CDI Week Industry Survey show less than 2% of the more than 600 respondents identified as working in outpatient/physician practice setting, and just under 40% say they review any type of outpatient records (such as hospital-based outpatient services, physician practices, outpatient rehab, etc.).

So why expand? What’s the benefit and where’s the impetus behind CDI expansion?

There’s a story here that hopefully most of you know well. First, healthcare costs in the United States are unsustainable. America spends 50% more than most other first-world countries on caring for its population. Second, that care is subpar. Various studies have placed deaths due to medical errors between 40,000 to as high as 200,000 per year, according to AHRQ’s Patient Safety Net.

Ever since the birth of the nation’s social security system with its nationalized healthcare system for the elderly and disabled, the country has struggled with various methods for how to pay for that care. Once it was a pay-for-service system, one that simply paid physicians and facilities for the services provided, no questions asked. That system rewarded quantity not quality.

Today, healthcare quality is more than a buzzword, it’s an enigma. How do we get to a point where our healthcare system can successfully sustain itself financially while honestly taking the best care of a population that’s not only aging but suffering from a wide-variety of ills?

Anyone who works in CDI knows how complicated the pay-for-quality (once dubbed pay-for-performance or P4P) system has become with various government initiatives overlapping and replacing an ever-more complicated morass of bureaucratic alphabet soup. It’s true on the inpatient side. It’s true on the outpatient side.

The Accountable Care Organization (ACO) brand of soup represents just one type, but it’s commonly these healthcare systems where the greatest steps in outpatient CDI has been seen of late. Pooling resources, ACOs understand where information overlap can benefit the entire system in terms of quality measure reporting and the effect that reporting has on the government’s carrot and stick reimbursement policies.

Those doing the daily work of inpatient or outpatient CDI record reviews needn’t trouble themselves with the percentage of withholdings versus the outcome scores of aggregate practices on particular measures—at least not at the granular level. However, anyone working in CDI needs to understand how obtaining detailed accurate documentation affects the broader aim of improved healthcare for our badly bruised system.

If your program isn’t working in the outpatient area yet, that doesn’t mean you shouldn’t inform yourself about these efforts. ACDIS has plenty of resources to help in this regard. Not the least of which is the new Certified Clinical Documentation Specialist-Outpatient (CCDS-O) credential but including a host of case study articles, white papers, position papers, and the third annual ACDIS Symposium: Outpatient CDI which takes place this November.

Here’s some links to some of these resources to help spark your learning: 

• Outpatient clinical documentation improvement (CDI): An introduction
• Queries in outpatient CDI: Developing a compliant, effective process
• CDI and the evolution from finance to quality
• White paper: Outpatient CDI model increases revenue opportunities and positions health system for future success (Sponsored)
• White Paper: Opportunities abound in outpatient clinical documentation improvement efforts (Sponsored)

Editor’s Note: Varnavas is the associate editorial director for ACDIS. Contact her at mvarnavas@acdis.org.