2023 CDI Week bonus Q&A: Outpatient CDI and risk adjustment

As part of the 13th annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Jessica Vaughn, DNP, RN, CCDS, CCDS-O, CRC, director of operations, condition management, and documentation at Advocate Health in Rolling Meadows, Illinois, answered these questions. For questions about 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: Our outpatient CDI program is not your typical CDI program. The program is highly matrixed, supported by physician leadership, includes a multidisciplinary focus, and is also patient centered. As a core program within enterprise population health, we call our department “condition management and documentation” (CMD) and focus on not only all facets of the revenue cycle from beginning to end, but also on patient engagement and assessment of care gaps. This includes pre-visit planning, real-time suspecting through the EHR, and retrospective payer reconciliation. Also, we have an entire team devoted to clinician engagement, and other teams devoted to outreach and comprehensive patient assessments.

Q: How is your outpatient program staffed? Do the same CDI specialists review both inpatient and outpatient records? If not, how often do inpatient and outpatient teams interact? How often does the outpatient team interact with coding/office management staff?

A: Our CMD program is staffed with registered nurses, certified coders, and IT professionals. As part of a larger population health initiative, we have a core team made up of interprofessional leadership that provides direction to CMD processes. As leaders, we collaborate and work closely with our inpatient CDI colleagues. Those performing CDI tasks, however, do not interact on a regular basis. The CMD team has work streams with both coding and physician engagement, however, and physicians and office staff are updated/educated on a regular basis.

Q: Which services do you review/not review? How did you decide which outpatient services to review/not review?

A: We mostly review Medicare Advantage and Medicare Shared Savings Program patients but have started reviewing commercial and some Medicaid too. The decision was based on business analysis as well as patient demographics. This decision was highly based upon organizational and community assessment and contracting so, therefore, may look different for each organization.

Q: According to the 2023 CDI Week Industry Survey results, 26.82% of respondents either have a dedicated outpatient program or have inpatient CDI also reviewing some outpatient records, which is nearly flat with 2022’s results. Additionally, 20.35% 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: First, you must know what you're trying to achieve. Programs tasked to review a certain area or to review certain payers may look different and quite honestly probably already have an upper hand over those trying to show proof of concept to executive leadership. Once you know what you're trying to do, then you must garner buy-in, both from physician leadership and business leadership. This is perhaps the most important concept. Try to remove barriers with data and knowledge while leveraging concepts that connect to the stakeholders. This may look different dependent upon your organization’s needs.

Q: Among those who currently review outpatient records, the most popular focus area was HCC capture (47.09%), and just over 40% said they review records prospectively. Why do you think this focus and review timing work well for outpatient programs? The prospective process is obviously much different from the traditional concurrent CDI review; do you have any tips for those expanding to these types of reviews?

A: I think CDI specialists can relate to the concept of HCCs even if they don’t fully understand risk adjustment, because they closely correlate to DRGs, severity of illness, and risk of mortality. HCCs are essentially showing similar concepts of care for the patient. I think the same for prospective reviews; even though the reviews are a bit different, they still feel like traditional CDI because they are as current as it gets in an ambulatory setting.

My tip is remembering that a patient record review is the same regardless of setting. The rules, time frame, etc. may be different, but the outcomes are the same: accuracy of the patient presentation to everyone who reads the chart. Keeping this in mind will help the CDI specialist complete their work without overthinking.   

Q: What does the query process look like for your outpatient CDI reviews? Do you have a separate policy for these queries, or is it combined with the inpatient query policy? Can you tell us a bit about your program’s outpatient query process? Is there a set policy governing those queries? What guidance/resources did you use to build that policy or procedure (i.e., did you reference the “ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice” or “Queries in Outpatient CDI: Developing a Compliant, Effective Process” recommendations into your practices)?

A: We query prospectively using alerts within the EHR. Our policy is centralized, combining all ambulatory CMD, inpatient CDI, and coding, and takes into consideration ACDIS and AHIMA standards. I think it’s important to have an overarching standard even if the actual query looks different or is in a different location and dependent upon the sourcing department.

Our ambulatory process uses internal algorithms that look at discrete data fields to surface clinically suspected conditions. We also use billing and claims data as well as a natural language processing vendor to help the nurses and coders identify what should be queried within the EHR. 

Q: In your opinion, do you think now’s the time for outpatient expansion? What do you think might be holding folks back from exploring this setting?

A: I think more than ever, now is the time for organizations to build upon their CDI processes and expand into ambulatory settings. Healthcare is moving quickly toward value-based care, and those who do not preemptively assess and create processes to address these requirements will be behind and, I believe, have a harder time catching up.

I feel that one barrier holding folks back is the lack of understanding of where to start. Whether it be risk adjustment or another model, change management takes time and effort and is uncomfortable to say the least. We don’t really have experts in all things ambulatory. Most of us are experts in one or two areas, but not all. Therefore, we must be open to exploring more interprofessional relationships and collaborative effort. This means ensuring contracting and payers who have not been part of the traditional CDI model have a seat at the table.