Symposium Spotlight: Building an outpatient CDI program in the ED

Editor’s note: Autumn Reiter, BSN, RN, CCDS, CDIP, CCS, director of CDI services for TrustHCS, based in Springfield, Missouri, will present “Five Pillars for Building a Successful CDI Program in Emergency Services and Other Outpatient Areas,” on Day 1 of the ACDIS Symposium: Outpatient CDI. This year’s Symposium takes place November 8-9, at the Hilton Orlando Lake Buena Vista—Disney Springs area. To see the complete agenda, click here. To register, click here.

ACDIS: Where do you think programs should begin to focus when considering a move into reviewing emergency department (ED) or other outpatient records?
Reiter: We’re starting from the client perceptive, asking them the question about where they want to begin. However, every CDI program should commence with analysis and research. You cannot make informed decisions unless you have a solid base of knowledge from which to start. That’s why we recommend conducting an audit to identify what areas of opportunity exist. Sometimes we think we know what the opportunities are, but after a closer look, these focus areas don’t turn out to be a problem or won’t yield the greatest outcomes.

ACDIS: What are some of the greatest opportunities that you’ve seen in the ED?
Reiter: Injections and infusions, medical necessity and denials. For example, on the medical necessity and denials side, we’ve found that ED tests often aren’t substantiated. A patient sent for a head CT scan without supportive documentation could lead to a denial—if this occurs several times over the course of a year it becomes very costly to the facility.

On injections and infusions, this isn’t a standard CDI review because nursing staff are likely the ones documenting. CDI professionals should review the record to make sure start and stop times are documented correctly. They can also help bridge the gap between the clinical documentation and what’s needed from a coding perspective. Educating the nursing staff or facilitating EHR notifications can impact revenue greatly.

ACDIS: What is the query process and/or timeline in the ED?
Reiter: We’re delivering the query in the same way the inpatient CDI team works, so there is consistency between the ED and the inpatient efforts with compliance throughout. Additionally, following a similar process allows the ED CDI staff to leverage the same electronic tools used by the inpatient team. Using available technology helps you avoid re-inventing the wheel.

However, anyone who has ever visited an ED knows how busy it is. The stress of frequent life-or-death situations combined with the mundane redundancy of clinic-style visits and needs of socially vulnerable patient populations makes approaching busy ED physicians for CDI queries a daunting task. So, the first step is to be mindful of the physician and patient flow, and to determine if there is a different way to deliver the query that may work better for the ED.

Then, educate the entire department on why CDI efforts matter. The ED has relatively been left in the dark about the CDI processes, but we’re working on a query process with a time-stamp and within a 24-hour period.

ACDIS: What is the staffing model for CDI in the ED?
Reiter: It is important that anyone working in the ED understands outpatient coding including ICD-10-CM/PCS, modifiers, current procedural terminology (CPT) and evaluation and management coding and leveling, and medical necessity denials. It’s preferable to have a CDI specialist with knowledge on these factors working in the ED. You can educate the right candidate, but the coding background is even more evident in this role than on the inpatient side. A strong understanding of CPT coding will enable the CDI to traverse this new area with greater ease.

Other factors to consider when hiring for this role include the individual’s clinical experience. You may consider looking for a  nurse with outpatient coding experience although not all programs may decide to hire just nurses.

Use your hospital census to determine what level of full-time equivalency (FTE) is needed to do the best job. In my opinion, most hospitals could easily support a full FTE in the ED. The ED is busier during the weekend because the doctors’ offices aren’t open. How you move those players around is still something we’re assessing.

Currently, TrustHCS supplies temporary CDI staffing for our clients. We support the pilot effort to achieve a return on investment for the client, helping them determine which staffing option is best—hire on-site staff or continue to contract with us. Right now, we’re starting out with one staff member in the ED and one in outpatient surgery. Generally, we anticipate it could take a facility roughly three to six months to prove a return on investment before they go to the staffing board and present a case for additional resources.

ACDIS: What do see as the role either in collaboration or in overlap with the case management or utilization review staff?
Reiter: There really needs to be effective provider education to help them understand what everyone’s role is and how each department is utilized. All departments should work as a team to get the information that’s needed, but not wear multiple hats to be effective. Understanding each other’s roles is essential for success

Case management can be beneficial to CDI in terms of how to assess the ED workflow and where to interject the CDI process.

ACDIS: What is the reporting structure?
Reiter: The ED program, preferably, is completely separate from the inpatient program. Even though they report up to the same director, outpatient needs have a separate reporting mechanism. Programs also need to determine the specific patient population under review in a given department or setting. Currently, the CDI ED program only reviews patients who were “treated and streeted,” discharged from the ED back home or to another care setting. Anyone who comes to ED and is then admitted to hospital belongs to inpatient.

ACDIS: What do you see as obstacles to success in this arena?
Reiter: If you’re familiar with the ED physicians, then it makes success easier. One of the major obstacles, like any CDI program, will likely be provider education and by-in. It’s similar to handling the difficult surgeon, it’s just a faster timeline.

ACDIS: What metrics do you look at when determining that ROI?
Reiter: Programs really need to target metrics to their program’s focus area. Where were the opportunities originally identified, what steps did the program take in capitalizing on those opportunities, what are the outcomes, and where are the barriers? You audit, implement, assess, and improve to understand how the CDI program moves the needle on each opportunity. That’s why the audit is so important in this area, otherwise you’re flying blind. That focus will change year to year but knowing that starting point and continually working towards improvement is vital for ongoing success.

ACDIS: Fun Question: What’s your favorite television show of all time?
Reiter: Walking Dead. I was actually working near the studio where they were filming and I kept hoping I would catch one of the actors in a local coffee shop or something. I never did. I can’t wait until the new season starts in October.