2022 CDI Week bonus Q&A: Outpatient CDI

As part of the twelfth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Maria Garcia (GiGi) Donohue, RN, BSN, CCDS, is the regional manager of clinical documentation excellence at Orlando Health in Florida. She is a member of the ACDIS CDI Leadership Council and the 2022 Furthering Education Committee. For questions about the committee or the Q&A, contact ACDIS Associate Editor Jess Fluegel (jfluegel@acdis.org).

Q: Can you define what “outpatient CDI” means to you/your organization?

A: Outpatient CDI means the complete review of patients' medical records in the ambulatory, emergency department, same-day, observation, or clinic setting to capture and support complete documentation of diagnoses, Hierarchical Condition Categories (HCC), medical necessity, and chronic conditions.

Q: According to the 2022 CDI Week Industry Survey results, 24.70% of respondents either have a dedicated outpatient program or have inpatient CDI also reviewing some outpatient records, which is nearly flat with 2021’s results. Additionally, 23.67% of respondents noted that while they do not currently have an outpatient CDI program, they plan to expand into outpatient. What advice do you have for those looking to expand into outpatient CDI?

A: I believe that an outpatient CDI program is beneficial for health organizations. I feel that team members to consider for this program should have inpatient and outpatient experience, but there are good educational options out there as well. Team members with inpatient CDI experience, who show interest in outpatient CDI, should be highly considered.

A few factors to consider and evaluate:

• Who are the right stakeholders?
• Do we have the right organizational structure in place?
• Can our current technology successfully support an outpatient CDI program?

Q: Among those who currently review outpatient records, the most popular focus area is HCC capture (58.52%), and just under half (40.74%) said they review records prospectively. Why do you think this focus and review timing work well for outpatient programs?

A: HCC is a risk adjustment model that identifies individuals with serious acute or chronic conditions, and as such, it is designed to estimate future healthcare costs for patients. Prospective review assesses the need for healthcare services before the service is performed, aligning with the prospective nature of risk adjustment methodology.

Q: In your opinion, why do you think now is the time for outpatient expansion, and what might be holding folks back from exploring this setting?

A: Hospital revenues are shifting from inpatient to outpatient, and the rate of growth of outpatient visits far outpaces inpatient discharges. Hospitals in turn have aggressively acquired physician practices to offset the decrease in inpatient revenues.

The HCC risk adjustment model under the Affordable Care Act has also accelerated things. Risk adjustment has become complicated as time has gone on, especially with the change from ICD-9 (which had roughly 3,000 codes) to ICD-10 (which has roughly 11,000 codes). This degree of specificity requires appropriate documentation, especially now that CMS has moved to a value-based reimbursement model. This aspect of documentation has become critical for revenue integrity.