As healthcare services migrate from inpatient to outpatient settings, a greater portion of most health systems' revenue is tied to clinical care — and thereby the clinical documentation — performed in the ambulatory space.
Yet few organizations have implemented consistent documentation practices throughout their enterprises. In fact, only 10 percent of hospitals reported having a clinical documentation program covering inpatient and ambulatory spaces in 2016, according to a survey by the Association of Clinical Documentation Improvement Specialists.
For this reason, health systems are seeing value in deploying clinical documentation specialists to improve documentation practices for outpatient services. Laura Jacquin, RN, partner at Prism, shared with Becker's Hospital Review six considerations for hospital leaders planning or preparing to implement outpatient CDI programs.
1. Some organizations define outpatient CDI as all hospital-based services outside the inpatient setting. Other organizations may limit outpatient CDI to documentation and coding in physician practices and clinics. Deciding what services and facilities fall under an organization's outpatient footprint is an important first step in designing an outpatient CDI program.
2. Before implementing an outpatient CDI program, organizations should gather data that help focus the program on key areas for improvement. Metrics such as improved quality indicators that track increased compliance with quality measures or improved financial outcomes can assist in identifying areas of opportunity.
3. Key to implementing an effective CDI program is accounting for an organization's unique needs in program design. Health system leaders should consider the following questions when implementing an outpatient CDI program:
- What is your organization's volume of denials for medical necessity of patient status?
- What is your organization's volume of medical necessity denials for outpatient surgical cases?
- Is your organization part of an accountable care organization?
- Do your providers participate in Medicare Advantage programs?
- Do your providers participate in any value-based payment programs?
4. Outpatient CDI programs present distinct challenges from inpatient CDI. For one, outpatient visits are substantially shorter than inpatient visits. Inpatient clinical documentation specialists may have several days to review documentation and query providers while the patient is in the acute care setting. Outpatient visits are significantly shorter — lasting 8 to 40 minutes in physician practices, on average — meaning a concurrent review by a clinical documentation specialist is much more challenging. Therefore, program leaders should have a structure in place for specialists to review documentation soon after the visit but before the bill is completed.
Furthermore, since patients are seen for shorter periods of time, outpatient CDI staff have less medical information to review and a greater case volume. Shorter episodes of care in ambulatory settings underscore the importance of quickly and accurately documenting, coding and submitting valid claims the first time. As such, productivity standards and number of CDI staff may vary according to the outpatient setting.
5. Physician engagement is critical to ensure the success of an outpatient CDI program. Often, program success depends on timely physician responses to queries from CDI staff. Therefore, physician education on the importance of documentation and the role of CDI will be key to securing buy-in and support on the front line.
6. Implementing an outpatient CDI program is no small feat. The following best practices can help organizations ensure their CDI programs have a solid foundation for facilitating timely, accurate coding and billing the first time.
- Determine optimal staffing levels across various outpatient locations and specialties to secure physician engagement and ensure program success.
- Establish collaborative working relationships with providers, coding staff and revenue cycle employees.
- Clearly define and communicate goals and objectives for the outpatient program.
- Implement efficient, effective workflows supporting financial and quality program objectives.
- Enforce programs that hold employees accountable for performance.