7th Annual Association for Clinical Documentation Improvement Specialists Conference 2 Emerging Outpatient CDI Drivers and Technologies Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA Outpatient Payment Specialist JA Thomas/Nuance Communications, Inc. Atlanta, Ga.
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Emerging Outpatient CDI Drivers and Technologies · ICD-10 CM/PCS • Volume of codes • Lack of familiarity with ICD-10-CM/PCS ... – When billed with any of the following ICD-9
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7th AnnualAssociation for Clinical Documentation
Improvement SpecialistsConference
2
Emerging Outpatient CDI Drivers and Technologies
Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA
Outpatient Payment Specialist
JA Thomas/Nuance Communications, Inc.
Atlanta, Ga.
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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
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Key Differences Between Inpatient & Outpatient
Documentation, Coding, & Billing
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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?”
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Outpatient
Professional
Hospital‐owned
Private practice
Facility
Ambulatory surgery
ED
Diagnostics
Clinics
Rehab, etc.
Outpatient Components
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Top Outpatient Claim Denial Reasons
• No documentation
• Incomplete or insufficient documentation
• Medically unnecessary
• Incorrectly coded
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Outpatient CDI Drivers
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Regulatory Drivers
Affordable Care Act (ACA)
Medicare Shared Savings Program
Accountable care organizations (ACOs)
Risk‐adjusted reimbursement
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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
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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
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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
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Example HCC Diagnoses
• Certain amputations
• Alcohol dependence, in remission
• Ostomy presence
• Obesity
Slate is wiped clean beginning of calendar year
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CDI Case Study
Risk markerIncremental 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
manifestations
$508 0.508
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
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ICD-10 CM/PCS
• 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
Unique Challenges
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Specificity Required in ICD-10-CM Codes
Covered ancillary services
J45.51
Severe persistent asthma with acute
exacerbation
S82.45A
Non‐displaced bimalleolar fracture of left lower leg, initial
– When billed with any of the following ICD-9 codes:• 733.00 through 733.03
• 733.09
• 722.90
• 255.0
Bone Mass Measurement (BMM)
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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
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Incorrect Coding
• 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
Examples
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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
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Billing Errors
• Failure to submit all codes
• Unbundling
• Incorrect units
• Incorrect revenue codes
• Differences between order and billed medication units
• Place of service errors
Examples
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Charge Description Master (CDM)
• 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
Identify and Initiate:
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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)
• 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
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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
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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
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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
• 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
CDI Elements of Success
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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.