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Five Steps to get Started in Outpatient CDI

By Brian Murphy

If you’re a CDI leader or HIM director, odds are there’s a voice ratting around in your head somewhere: I need an outpatient CDI program.

These days, such thoughts are not a surprise. According to recent ACDIS survey data, only 20.6% of organizations have a standalone outpatient CDI program, but another 22% were planning to expand into OP CDI this year. (1)

There are many reasons you might feel a need to get started in OP CDI. Just a few include:

  • Peer pressure—your friendly neighborhood competitor down the street has one. Not the best reason to get into OP CDI, but it’s real.
  • Changing payment landscape. More patients are abandoning traditional Medicare for Medicare Advantage, which uses capitated payments and something called Hierarchical Condition Categories (HCCs) instead of DRGs. CMS aims to have all Part A and B Medicare beneficiaries to be in a care relationship with accountability for quality and total cost of care—and most Medicaid beneficiaries as well.
  • Missing impact: Your inpatient CDI program can improve HCC capture, but you know something is being missed from those thousands of unreviewed outpatient clinic encounters—chronic conditions.

So, how do you begin to address this gnawing FOMO?

The tempting method is to just start doing something in a hurry. Whatever that something is. Grabbing charts at random and clarifying diabetes types, because you heard that was the thing to do.

Unfortunately going to work without a blueprint leads to a lot of effort, and few to no tangible results. And quite likely to failure.

Instead, we recommend an orderly approach that involves a plan. The following are five recommended steps to get you moving in the right direction.

Step 1: Identify Your Stakeholders

Your stakeholders are probably not who you think.

They’re not just the CDI specialist you’ve pulled over from acute to launch this new initiative. They’re not just physicians.

These are your stakeholders, but only a couple. They’re also your contracting department, your quality staff, and your patient registration team.

They might also be your vendor, if you have a potentially helpful tool floating around that you may not know how to use.

If you operate as part of an accountable care organization (ACO), you might have an ACO leadership group that you need to engage. You also need to consider payer contracting, and population health, if you have a dedicated department.

But most of all, your biggest stakeholder will be your hospital’s executive leadership. Without them you won’t be able to muster the resources you need (people, technology, etc.).

CDI impacts care across the entire health care continuum, but CDI professionals have a tendency to only focus on day-to-day chart reviews and not the bigger picture. “Many CDI programs are a bit siloed,” says Dr. Jessica Vaughn, DNP, RN, CCDS, CCDS-O, CRC, vice president of value-based CDI for Norwood.

Once you’ve identified this list of stakeholders, work as a team to develop one clear purpose and a common, agreed-upon set of goals. Meet weekly with your team to define your goals and mission statement. This leads us to the work of step 2.

Step 2: Understand How Your Contracts Work

A deep understanding of your contracts might reveal that most of your RAF opportunity lies in your primary care clinics, for example. One large national organization started in outpatient CDI due to poor performance on a risk-based contract. By digging into the details the organization was able to find its focus, begin work, and make concrete improvements.

Make sure the contracts you review contain tangible opportunity: You might spend time with providers to improve their documentation only to find that there is no gainsharing in the contract, for example, resulting in a lost financial opportunity. “Even though this may be a great way to interject with best documentation practices, it doesn’t do much to satisfy the CFO need to show concrete ROI,” Vaughn says.

Focus on the one contract where you have the most risk for the calendar year, or on prior authorization denials. Even a 1%–2% difference on a large contract can satisfy organizational need to prove ROI

Primary care clinics and improved HCC capture typically offer the most opportunity. However, you may also discover significant opportunity in hospital acquired infections (CAUTI, CLABSI, c-diff, and MRSA) and surgical site infections, the reduction of which can positively impact hospital value-based purchasing quality measures and indirect revenues.

Step 3: Present Your Findings to Organizational Leadership 

Next, take your data from your contracts, coupled with your proposed mission statement and objectives as developed by your stakeholders, and present your findings to organizational leadership. Show the potential financial ROI. Ask for input and feedback.

ROI does not just mean revenue. Stress the positive impact on patient care, not just the finances. Selling outpatient CDI as only a financial benefit does not sit well with most physicians; moreover, it paints an incomplete picture of the benefits improved documentation can bring. Having the most accurate and up-to-date chronic conditions on the chart helps care managers and those focused on population health initiatives better assess needs, identify trends of high risk, and address deficiencies and inequities by placing resources, such as nurses, in under-resourced areas.

For example, a CDI program that captures risk in the clinic setting can better help manage diabetic patients through capture of the condition and better prescribed treatment and patient outcomes, as is seen in the literature of community care diabetes programs.

During record review of clinic encounters, you will likely find examples of gaps in care, for example lab work or urine cultures that haven’t been followed up on. You can take these findings back to quality, to inpatient teams concerned about readmissions, and practice councils. “It’s not just about HCC capture, it is about patient care, and that’s something you can take back to administration,” Vaughn says. “The goal of value-based care is to keep patients out of the hospital, and get them taken care of in the community with the right amount of resources.”

This step also helps to ensure organizational buy-in and alignment. 

Step 4: Start Small, With a Pilot 

Once you’ve got your stakeholders assembled, your contracts squared away, and your leadership nodding its head, you need to start… small. Focus on one thing (we can’t stress this enough).

There are so many avenues in outpatient CDI to pursue, and if you chase them all you’ll be the proverbial headless chicken.

For Vaughn, that means starting with primary care clinics and HCC optimization. Most RAF opportunity begins there, as many patients have their chronic conditions coded from these visits. Start small. Her previous organization selected three clinics from dozens and focused their efforts there. These became the pilot project. They placed CDI specialists directly in these three clinics to provide face-to-face clinician education and help ensure buy-in.

The organization’s stated goal was to bridge the gap between clinician documentation and coding guidelines for ICD-10 specificity and HCC optimization. Critically, it decided not to clarify CPT or HCPCS codes, or review of observation cases, as this would have led to too broad a focus.

At first they performed three months’ worth of retrospective reviews, not to change codes or issue queries, but to identify opportunities, and establish a set number of daily prospective reviews (that number eventually settled on a target number of 26—threshold 22, optimal 30). These retrospective reviews revealed that the organization had the most opportunity in Type 2 diabetes specificity (with hyperglycemia, with diabetic polyneuropathy, long term insulin use, etc.), morbid obesity/BMI, alcohol and drug dependence, Parkinson’s, major depression, AKI, A-fib (specified as chronic or paroxysmal), CHF, and COPD/asthma.

Armed with this data, they then developed a process for reviewing records prospectively, querying and educating physicians on the need for more complete, accurate, and specific documentation prior to the patient visit, as well as assisting with problem list cleanup.

Note that starting small requires a lot of the last step, which is…

Step 5: Be Patient 

This process described above will likely take a year or more to fully implement, not a few months. You can’t move the RAF needle in a week, or a month. It may be a full calendar year or more before you start seeing ROI and other impacts.

Vaughn’s prior organization began building its OP CDI program in 2015 with two dedicated nurses, and it wasn’t truly humming along until 2018.

Three years later the OP program had seven full time reviewers and a dedicated data analyst reviewing trends and reporting progress to administration. The process went from retrospective to prospective reviews completed 24-48 hours prior to the scheduled visit.

In the last couple years they’ve upgraded with streamlined processes and a new vendor tool. In addition to primary care and general medicine clinics, they now cover seven specialties including endocrinology, pulmonary, nephrology, neurology, cardiology, vascular, and behavioral health.

The work never ends. But, we believe that with this type of organized approach you’ll reap the dividends, which include better quality, better reimbursement, and ultimately better care across your organization.

Want to learn more about what we call value-based CDI? Start with our first article in this ongoing series.

Does the above sound daunting? The experts at Norwood can help you get there. We’d love to hear from you. Send an email to Jessica Vaughn at jessica@norwood.com, even if you just have questions about this article or need a bit of advice. Promise, she won’t bite.

About Jessica Vaughn

Jessica Vaughn, DNP, RN, CCDS, CCDS-O, CRC, is Vice President, Value-Based CDI for Norwood. She has more than 11 years of CDI experience and 25 years of nursing experience. In 2015 she started and led one of the nation’s first and extraordinarily successful outpatient programs at Wake Forest Baptist Health, focused on value-based care for Population Health. She is a leader in the industry, having spoken at multiple conferences, authored articles, received ACDIS’s National Professional Achievement Award in 2016, and helped write both the ACDIS CCDS-O study guide and the certification exam. Jessica recently earned her Doctorate of Nursing in Executive Leadership at Duke University.

About the author

Brian Murphy is the founder and former director of the Association of Clinical Documentation Integrity Specialists (2007-2022). In his current role as Branding Director of Norwood he enhances and elevates careers of mid-revenue cycle healthcare professionals.

References

ACDIS, 2021 CDI Week Industry Overview Survey, September 2021. Accessed at https://acdis.org/system/files/cdi-week/CR-5142%20CDI%20Week%20Industry%20Survey%202021_final%20%281%29.pdf

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