7th Annual Association for Clinical Documentation Improvement Specialists Conference Emerging Outpatient CDI Drivers and Technologies Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA Outpatient Payment Specialist JA Thomas/Nuance Communications, Inc. Atlanta, Ga. 2
Learning Objectives At the completion of this program, the learner will be able to: Evaluate key differences between inpatient and outpatient documentation, coding, and billing Identify outpatient CDI drivers and objectives Examine outpatient CDI strategies, resources, and methodologies Discuss ways to overcome the specific challenges of ICD-10 outpatient documentation List tips to maximize outpatient CDI program effectiveness 3 Key Differences Between Inpatient & Outpatient Documentation, Coding, & Billing 4
Inpatient and Outpatient CDI Compare and Contrast Inpatient Decreasing volume Fewer variables Clinical focus Less provider interaction Single setting Less focus on charges Outpatient Increasing volume Constant change Business and clinical focus More provider interaction Disparate settings Charge description master (CDM) Is the setting correct? Has there been previous failed treatment? 5 Outpatient Components Outpatient Professional Facility Hospitalowned Private practice Ambulatory surgery ED Diagnostics Clinics Rehab, etc. 6
Top Outpatient Claim Denial Reasons No documentation Incomplete or insufficient documentation Medically unnecessary Incorrectly coded 7 Outpatient CDI Drivers 8
Regulatory Drivers Affordable Care Act (ACA) Medicare Shared Savings Program Accountable care organizations (ACOs) Risk adjusted reimbursement 9 Hierarchical Condition Categories (HCCs) Risk-adjusted capitation Uses data to prospectively estimate predicted costs in the next year based on: Demographic information & A profile of major medical conditions in the base year 10
HCC Impact to Providers Medicare Advantage capitation payment Shared Savings Program Accountable care organizations Historical benchmark expenditures adjusted based on CMS-HCC model Medicare Physician Quality and Resource Use Reports 11 HCCs HCC concept similar to DRGs Each member (patient) has Risk Adjustment Factor (RAF) score Organization average RAF score similar to case mix Score of 1 represents typical patient Less than 1 is healthy patient Greater than 1 likely patient utilizes greater resources Certain diagnoses increase RAF Similar to CCs and MCCs Usually chronic conditions Any encounter or episode in calendar year 12
Example HCC Diagnoses Certain amputations Alcohol dependence, in remission Ostomy presence Obesity Slate is wiped clean beginning of calendar year 13 CDI Case Study Risk marker Incremental prediction (sample rate $1,000 * risk factor) Relative risk factor Scenario #1 (deficient documentation) Female, age 75 79 $457 0.457 Diabetes mellitus $162 0.162 UTI $0 0.0 Total $619 0.619 Scenario #2 (same patient accurate documentation) Female, age 75 79 $457 0.457 Diabetes mellitus w/renal $508 0.508 manifestations UTI $0 0.0 Diabetic nephropathy $0 Trumped by CKD stage 3 CKD stage 3 $368 0.368 Mild degree malnutrition $856 0.856 Old MI $244 0.244 BKA status $678 0.678 Total $3,111 3.111 Difference $2,492 2.492 14
ICD-10 CM/PCS Unique Challenges Volume of codes Lack of familiarity with ICD-10-CM/PCS Limited coding advice Inadequate documentation to support procedures and diagnoses New and revised coding guidelines Dealing with dual code sets 15 Specificity Required in ICD-10-CM Codes Covered ancillary services Non covered ancillary services J45.51 Severe persistent asthma with acute exacerbation J45.909 Asthma, NOS S82.45A Non displaced bimalleolar fracture of left lower leg, initial encounter S82.899 Other fracture of unspecified lower leg 16
Technology Drivers Computer-assisted coding Computer-assisted physician documentation Computer-assisted clinical documentation improvement 17 The Technology Advantage Natural language processing Electronically capture codes & clarifications Enhance CDIS and coder productivity Track patients, identify risks, monitor outcomes, improve core and quality measures 18
Outpatient CDI Strategies, Resources, and Methodologies Overcome ICD-10 Challenges 19 Incomplete & Insufficient Documentation Examples Infusion start and stop times Missing comorbid conditions Lack of specificity Failure to document links between various conditions Date of service errors 20
Case Study Intravenous Infusion CPT Codes CPT code Description Time parameters 96360 Intravenous infusion, hydration, 31 minutes to one hour initial 96361 Each additional hour List separately in addition to code for primary procedure 96365 Intravenous infusion, for therapy, prophylaxis or diagnosis, specify substance or drug Up to one hour 96366 Each additional hour List separately in addition to code for primary procedure 96413 Chemotherapy administration, intravenous infusion technique Up to one hour, single or initial substance/drug 96415 Each additional hour List separately in addition to code for primary procedure 1st qualifying initial hour must be at least 15 min. Only if infusion interval time > 30 minutes 1 hour increment 21 Lack of Medical Necessity Examples NCD/LCD noncompliance High-cost medications Exceeding defined service frequencies such as units per day or yearly limitations Excessive medication units 22
Not Assumed That Because Treating Clinician: Orders Prescribes Approves or Directs a service that the healthcare service is medically necessary! 23 Case Study Bone Mass Measurement (BMM) Contractors shall allow CPT 77080 Dual energy x-ray absorptiometry: BMM When billed with any of the following ICD-9 codes: 733.00 through 733.03 733.09 722.90 255.0 24
Avoid Medical Necessity Denials Create written policies Encourage orders to be received 24 48 hours in advance of test Allows for pre-screening of orders Hire certified coder or nurse to review orders received in advance for medical necessity Require physicians to attach ABN to order Require provision of provider contact number 25 Incorrect Coding Examples Insufficient coder skill and experience Limited communication with provider Coding possible, probable, rule-out Missing comorbid conditions Inappropriate use of modifiers Untimed codes Charge description master errors 26
Uncertain Diagnosis Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis or other similar terms indicating uncertainty Rather, code condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit This differs from coding practices in short term, acute, long term, and psychiatric hospitals 27 Billing Errors Examples Failure to submit all codes Unbundling Incorrect units Incorrect revenue codes Differences between order and billed medication units Place of service errors 28
Charge Description Master (CDM) Identify and Initiate: Bundling rules, or what is included in each CDM item/service that is not separately reportable Which services are reported in specific time increments and the rules surrounding such reporting For pharmacy, billable units, wastage documentation requirements and associated acceptable billing practices Back-end processes to evaluate claim accuracy Retrospective audits 29 Benefits of Outpatient CDI Program Improve clinical documentation Reduce medical necessity denials Reflect accurate severity-adjusted profiles Support increasing adoption of value-based and risk adjustment payment models Meet demands of accountable care organizations (ACOs) Negotiate fair contracts 30
Before Starting High volume high risk Deep dive Identify services Revenue cycle Document risk Prioritize focus Volume Risk Denials 31 Getting Started Align CDI with revenue cycle processes If it s not documented, it didn t happen! 32
Outpatient CDI Process Assess Educate Remediate Monitor 33 Assess Denials measurement Dollar, weekly, monthly, YTD volume Historic versus current Identify denial trends and patterns Focus on high-dollar denials Rework measurement Dollar and volume 34
Educate Explain documentation requirements Educate providers on what information is needed to code Engage physicians and staff What s in it for me? Assist provider in ensuring patient(s) receive benefits they are entitled to based on physician properly expressing their clinical judgment and medical decision-making Assist provider document rationale for ordering, prescribing and providing 35 Remediate Establish timelines, goals, and objectives Conduct root cause analyses Develop internal query process to keep communication between provider and coder open Redefine concurrent Create internal policy to promote quality coding processes and avoid unspecified codes Update EHR templates Reimbursement cannot be a consideration Utilize technology to manage volume 36
ICD-10 CM/PCS Specific Remediation Eliminate coding cheat sheets Otherwise unspecified codes will persist No incentive for documentation improvement Implement or update EHR templates Support documentation for new ICD-10 CM/PCS codes Base ICD-10 CDI initiatives on unique needs of organization s providers, coders, and staff Ensure training addresses relevant, real-life patient encounters Use hands-on clinical documentation and coding exercises 37 Monitor Quarterly chart reviews for quality of clinical documentation Indications for procedure How many orders require clarification or rework Number of denials and appeal letters Denial rates and $ impact Numbers of questions or volumes of communication from physicians Percentage of cases with documentation deficiencies 38
Summary CDI Elements of Success Expand clinical documentation improvement beyond inpatient Focus on compliant documentation and medical necessity Align outpatient CDI program with ICD-10 CM/PCS initiatives Utilize technology as a resource Ensure relevant training Provide ongoing assessment Engage outpatient CDI professionals 39 Thank you. Questions? In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the workbook. 40