Presentation from ACDIS 2011 conference on outpatient clinical documentation improvement (OP-CDI)

2. Outpatient CDI: The New Frontier? Caroline Rader, Associate Director Navigant Consulting, Inc. caroline.rader@navigantconsulting.com

3. Objectives Upon completion of this educational session, the participants will have a better understanding of the following: The healthcare environment as it pertains to the shift to the outpatient setting The need for an OP-CDI initiative or program The differences between the traditional approach to CDI and approaches in the outpatient setting The general approach to assessing the need for an OP-CDI program and implementing changes towards sustainable improvement

4. Trends in the Delivery of Healthcare Healthcare expenditures for outpatient hospital and physician care are growing at a rapid rate Many facilities and providers have not traditionally focused efforts on the quality of documentation and coding of outpatient services

5. Trends in the Delivery of Healthcare (cont.) As patient volumes shift to outpatient services, regulatory actions and payer scrutiny are following Outpatient services are easier and quicker to audit and identify issues The onset of ICD-10 is requiring increased specificity in documentation to process a claim

7. Comparing Traditional CDI to OP-CDI (cont.) Documentation issues are universal, regardless of the coder, provider, or setting In the outpatient setting, the implication associated with inadequacies in documentation is not how much a facility may be reimbursed, but whether the facility is paid at all for the services rendered

8. Inpatient diagnosis coding Outpatient diagnosis coding The inpatient coder can code diagnoses documented as possible, probable, or not ruled out as if they exist The inpatient coder can review for additional diagnoses, but before they can be included in the patient encounter, the provider must confirm and verify (i.e., query) The inpatient coder must understand the complexities of assigning the principal diagnosis The inpatient coder can add secondary diagnoses The outpatient coder must have a confirmed diagnosis to assign the codes; otherwise, one must default to coding the known symptoms that prompted the patient to seek medical care The outpatient coder can reference other findings documented by the performing provider if available without the provider’s confirmation (i.e., query) The outpatient coder codes for the “first listed diagnosis” The outpatient coder can provide for additional diagnoses that describe any coexisting conditions Comparing Traditional CDI to OP-CDI (cont.)

9. Inpatient procedure coding Outpatient procedure coding The inpatient coder uses ICD-9-PCS codes, which are minimally descriptive. Code descriptions are tailored to hospital resource consumption rather than physician’s skill level as in CPT/HCPCS coding. The inpatient coder codes the procedure performed; however, they are not primary driver of payment in an inpatient environment. The outpatient coder uses CPT/HCPCS codes for hospital outpatient AND physician services. These codes are more descriptive. The outpatient coder pays most attention to the procedures performed and often those associated ancillaries. Some even review for higher-dollar pharmaceuticals and supplies. It is the CPT/HCPCS that is the primary driver of payment in the outpatient environment. Comparing Traditional CDI to OP-CDI (cont.)

10. Benefits of an OP-CDI Program

11. Benefits of an OP-CDI Program (cont.)

12. Understanding the Need for anOP-CDI Program The first step is to identify opportunities for documentation improvement; however, it is very common to uncover other areas of focus that may include: General coding and billing compliance Charge description master issues Inappropriate use of encounter forms, charge tickets, and automated charge capture tools Coder quality Overall data integrity issues across clinical and financial systems

13. Understanding the Need for anOP-CDI Program (cont.) Knowing what data and practices to review is critical to prioritizing any OP-CDI efforts Basics you should understand: How are outpatient services documented and coded? How are potential issues with the documentation and/or coding communicated? How are potential issues with the documentation and/or coding resolved?

14. Understanding the Need for anOP-CDI Program (cont.) Common source documentation and coding responsibility Outpatient Hospital Facility

15. Understanding the Need for anOP-CDI Program (cont.) Common source documentation and coding top 3 issues found Outpatient Hospital Facility

17. Visit level determination

18. Lack of national standard

19. Eleven standards for development of guidelines

20. Common methodology pros and cons

21. Separate and reportable items/services

22. ObservationAverage variance rate > 30%

24. Coding hierarchy

25. Start and stop times

26. Concurrent therapy

27. Sequential therapy

28. DocumentationAverage variance rate > 60%

30. Span of documentation

31. Dates of service

32. Image records

33. Frequency requirements for procedure coding

34. Physician supervision

35. Devices and treatment planning

36. Documentation of physician services

37. Documentation of physician weekly treatmentAverage variance rate > 30%

39. Denials for medical necessity

40. Denials for coding issues

41. Increased or sustained encoder or claims scrubber edits

42. Results of internal or external audits

44. Understanding the Need for anOP-CDI Program (cont.) Case study #2 A rural community hospital has received numerous complaints regarding the level of ED services billed by the hospital. One particular example is the billing of a Level V visit for a child presenting with pink eye.

45. Understanding the Need for anOP-CDI Program (cont.) Case study #3 A regional medical center has been audited by Medicare and placed under 100% pre-payment review for the use of a particular pharmaceutical in the medical oncology infusion clinic. Even after efforts to better the coding by educating office administrative staff and physicians, the error rate after 3 months is > 30%.

46. Identifying Opportunities for OP-CDI To know where the opportunities may exist ... look, see, and listen! LOOK for opportunities to improve upon your numbers SEE the process, not just the coding and documentation LISTEN to the staff ... they are in the weeds and they know the issues

47. Questions