Caroline Rader, Associate Director Navigant Consulting, Inc. Outpatient CDI: The New Frontier?

Objectives Upon completion of this educational session, the participants will have a better understanding of the following: – The healthcare environment as it pertains to the shift to the outpatient setting – The need for an OP-CDI initiative or program – The differences between the traditional approach to CDI and approaches in the outpatient setting – The general approach to assessing the need for an OP-CDI program and implementing changes towards sustainable improvement

Trends in the Delivery of Healthcare Healthcare expenditures for outpatient hospital and physician care are growing at a rapid rate Many facilities and providers have not traditionally focused efforts on the quality of documentation and coding of outpatient services

Trends in the Delivery of Healthcare (cont.) As patient volumes shift to outpatient services, regulatory actions and payer scrutiny are following Outpatient services are easier and quicker to audit and identify issues The onset of ICD-10 is requiring increased specificity in documentation to process a claim

Comparing Traditional CDI to OP-CDI Traditional approaches to an inpatient CDI program (e.g., concurrent review, real-time queries) are not well supported in an outpatient environment Inpatient CDI does not consider the capture of charges and CPT/HCPCS coding of ancillary services, data driven from the CDM or the professional fee charge capture and coding of services rendered

Comparing Traditional CDI to OP-CDI (cont.) Outpatient services are: – Provided in greater quantity – Provided in a shorter span of time – Occur simultaneously with other services – Involve different coding guidelines and systems – Rely heavily on documentation from nonphysician staff (e.g., therapists, nurses) – Utilize a higher degree of computerization – Utilize automated processes for code selection

Comparing Traditional CDI to OP-CDI (cont.) Documentation issues are universal, regardless of the coder, provider, or setting In the outpatient setting, the implication associated with inadequacies in documentation is not how much a facility may be reimbursed, but whether the facility is paid at all for the services rendered

The inpatient coder can code diagnoses documented as possible, probable, or not ruled out as if they exist The inpatient coder can review for additional diagnoses, but before they can be included in the patient encounter, the provider must confirm and verify (i.e., query) The inpatient coder must understand the complexities of assigning the principal diagnosis The inpatient coder can add secondary diagnoses The outpatient coder must have a confirmed diagnosis to assign the codes; otherwise, one must default to coding the known symptoms that prompted the patient to seek medical care The outpatient coder can reference other findings documented by the performing provider if available without the provider’s confirmation (i.e., query) The outpatient coder codes for the “first listed diagnosis” The outpatient coder can provide for additional diagnoses that describe any coexisting conditions Inpatient diagnosis coding Outpatient diagnosis coding Comparing Traditional CDI to OP-CDI (cont.)

The inpatient coder uses ICD-9-PCS codes, which are minimally descriptive. Code descriptions are tailored to hospital resource consumption rather than physician’s skill level as in CPT/HCPCS coding. The inpatient coder codes the procedure performed; however, they are not primary driver of payment in an inpatient environment. The outpatient coder uses CPT/HCPCS codes for hospital outpatient AND physician services. These codes are more descriptive. The outpatient coder pays most attention to the procedures performed and often those associated ancillaries. Some even review for higher-dollar pharmaceuticals and supplies. It is the CPT/HCPCS that is the primary driver of payment in the outpatient environment. Inpatient procedure coding Outpatient procedure coding Comparing Traditional CDI to OP-CDI (cont.)

Benefits of an OP-CDI Program Drives appropriate code selection for accurate reimbursement Is accurately and compliantly captured at the point of service Meets regulatory standards for clinical documentation, medical necessity, and overall charge capture Reduces risks from incomplete or unclear documentationSupports high-quality care

Benefits of an OP-CDI Program (cont.) Improved internal reporting Reduced days in A/R Increased net revenue Achieved greater results Through proactive education, auditing, and monitoring Through improvements in overall charge capture & coding Regarding resource utilization, costs of services, & other benchmarks Through complete documentation & charge capture

Understanding the Need for an OP-CDI Program The first step is to identify opportunities for documentation improvement; however, it is very common to uncover other areas of focus that may include: – General coding and billing compliance – Charge description master issues – Inappropriate use of encounter forms, charge tickets, and automated charge capture tools – Coder quality – Overall data integrity issues across clinical and financial systems

Understanding the Need for an OP-CDI Program (cont.) Knowing what data and practices to review is critical to prioritizing any OP-CDI efforts Basics you should understand: – How are outpatient services documented and coded? – How are potential issues with the documentation and/or coding communicated? – How are potential issues with the documentation and/or coding resolved?

Understanding the Need for an OP-CDI Program (cont.) Common source documentation and coding responsibility Outpatient Hospital Facility

Understanding the Need for an OP-CDI Program (cont.) Common source documentation and coding top 3 issues found Outpatient Hospital Facility

Understanding the Need for an OP-CDI Program (cont.) Emergency services considerations – Visit level determination – Lack of national standard – Eleven standards for development of guidelines – Common methodology pros and cons – Separate and reportable items/services – Observation Average variance rate > 30%

Understanding the Need for an OP-CDI Program (cont.) Infusion therapy considerations – Coding hierarchy – Start and stop times – Concurrent therapy – Sequential therapy – Documentation Average variance rate > 60%

Understanding the Need for an OP-CDI Program (cont.) Radiation oncology considerations – Span of documentation – Dates of service – Image records – Frequency requirements for procedure coding Physician supervision Devices and treatment planning Documentation of physician services Documentation of physician weekly treatment Average variance rate > 30%

Understanding the Need for an OP-CDI Program (cont.) Key indicators for determining if an OP-CDI may work for your facility or physicians Revenue unbilled (DFNB) Denials for medical necessity Denials for coding issues Increased or sustained encoder or claims scrubber edits Results of internal or external audits Increased costs with decrease in revenue

Understanding the Need for an OP-CDI Program (cont.) Case study #1 A large academic medical center has an increase in DFNB for electrocardiograms beginning in January. The internal claims scrubber is identifying accounts for review for not meeting Medicare’s medical necessity guidelines. Within 3 months, the total DFNB gross revenue associated with this edit is > $250,000 and growing.

Understanding the Need for an OP-CDI Program (cont.) Case study #2 A rural community hospital has received numerous complaints regarding the level of ED services billed by the hospital. One particular example is the billing of a Level V visit for a child presenting with pink eye.

Understanding the Need for an OP-CDI Program (cont.) Case study #3 A regional medical center has been audited by Medicare and placed under 100% pre-payment review for the use of a particular pharmaceutical in the medical oncology infusion clinic. Even after efforts to better the coding by educating office administrative staff and physicians, the error rate after 3 months is > 30%.

Identifying Opportunities for OP-CDI To know where the opportunities may exist... look, see, and listen! – LOOK for opportunities to improve upon your numbers – SEE the process, not just the coding and documentation – LISTEN to the staff... they are in the weeds and they know the issues

Questions