What is your CDI chart review process in the outpatient setting? One organization’s is very thorough

By Brian Murphy

Among the highlights of my interview with current Off the Record guest Glenda Bocskovits was hearing about her organization’s process of outpatient CDI chart review. Which is very thorough.

The practice of OP CDI is an art, with no one right way. If I were to hazard a guess, I’d say most programs perform pre-visit reviews, looking at previous encounters, previously documented chronic disease, medication lists, etc., and then “teeing up” the provider to address these diagnoses during the visit.

But that’s not set in stone. Other programs for example review the encounter retroactively, then educate the provider on the findings.

I’ve even heard of rare programs that perform no queries at all, but instead prefer to educate.

What you rarely see in the OP setting is concurrent reviews.

Glenda performs all three types with Catholic Health—pre, concurrent, and auditing on the back end—easily the most robust system of review I’ve heard about anyway.

Concurrent had me the most interested. While she’s not actually performing the review during a 20-minute clinic visit, she is reviewing the encounter pre-bill, often the same day. From our podcast interview:

“I call it concurrent, but its pre-bill, before the bill goes out, being able to look at it either that day in the afternoon, after the morning patients are seen or that next morning and see if the clinicians were able to document everything that you had shown them pre-visit wise and coded appropriately with the appropriate E/M level, the appropriate diagnosis codes, the HCCs, assess everything appropriately and document appropriately, you’re getting the funds for next year attributed to that patient so that they can be well cared for.”

The final step is a post visit audit for educational purposes.

Per Glenda typical clarifications include the following:

1. Additional specificity. For example, the provider might document Type 2 diabetes with complications but then fail to document the complication.
2. The provider notes a diabetic complication, and documents hypotension and hyperlipidemia and CKD, but fails to note which is the complication.
3. An absent diagnosis altogether in the presence of clinical indicators. For example, the provider might document “sending the patient to a nephrologist” for increased creatinine level, but fail to document CKD or AKI.
4. Note bloat/copy and paste. Ambient listening and AI generated notes are a helpful tool, but providers don’t edit out the noise (believing more=better).
5. Absent detail. For example, a medication is not tied to a diagnosis, or documentation of “ordered labs” without noting what labs were ordered.

All of this makes a robust chart review process a must, and Catholic Health certainly has one. Listen to the full episode here.