As the health care industry segues to value-based care models, providers are pursuing greater operational efficiency to achieve the Triple Aim: improving patient experience and outcomes while reducing the cost of care. Clinical documentation initiatives have long been championed as a means to meeting this end within inpatient settings. More recently, clinical documentation improvement programs have increasingly surfaced in outpatient settings, where a significant portion of patient encounters take place.

Thorough diagnosis documentation supports an in-depth view of patient history and risk factors, enabling clinicians to tailor individual care programs to foster better patient outcomes. Greater specificity in clinical patient data capture equips care teams with the insight needed to identify and prioritize at-risk patients and promote interventions that can diminish the need for costlier medical procedures down the road. Improved documentation also eases care team collaboration across patient care settings and over time.

Outpatient CDI case in point

Delaware-based Christiana Care Health System, which operates two hospitals with more than 1,100 beds and a network of more than 300 primary care physicians, started its inpatient CDI program in 2007. In October 2016 the health system’s executive vice president of quality and patient safety suggested expanding the program to better support hierarchical condition category capture in outpatient settings.

“We had executive support from day one,” says Karen Frosch, who serves as Christiana Care's CDI project manager. “We saw our primary care physician’s Medicare Advantage patients as an opportunity to test the waters of outpatient CDI among a targeted subset of patients,” says Frosch. “We assigned one CDI specialist to review practice documentation with physicians starting in November of 2016.” To improve code specificity and accuracy, the health system rolled out a plan to incrementally improve physician practice documentation over time, with long-term plans to expand efforts to specialty practices.

Reasons to expand to outpatient CDI

A desire to grow PCP awareness of the relationship between office documentation, patient outcomes and quality reporting prompted Christiana Care’s outpatient endeavor. “Documentation and codes now underlie practically every value-based initiative,” Frosch explains. “Their importance for physician practices and other outpatient service providers has grown exponentially under value-based care and quality payment programs.”

In most of Christiana Care’s practices, clinicians assign their own codes via electronic health record drop-down menus. Frosch’s team looks at the codes selected by the physician and provides education to promote granular coding and reduce the potential for claims rejections and denials.

The overarching goal of Christiana Care’s outpatient CDI initiative is to make physician claims as clean as possible as they go out the door. “Many of our physician queries offer an opportunity to clarify documentation and educate physicians,” says Frosch. “We want diagnoses thoroughly noted and coded in the patient’s record for continuing care and future hospital admissions.”

Lessons learned in physician documentation reviews

Christiana Care has one CDI specialist assigned to work with PCPs on their Medicare Advantage patients. She brings five years of inpatient CDI experience and physician billing and education expertise to the role. Clinicians particularly appreciate the help with code assignment. The CDI specialist visits one to two PCP practices per week in person and does much of her work remotely.

Thus far into the program, Christiana Care has observed that many coding opportunities have to do with “current state” versus “history of” code assignments. “When to assign the initial or subsequent visit character is another education opportunity we’ve identified,” says Frosch. “We’re keenly focused here to educate our physicians on these coding intricacies.”

Frosch shared some of the challenges and lessons Christiana Care has learned along the way:

  • Don’t overquery your physicians.
  • Learn the outpatient practice coding and documentation workflow, which can be dramatically different from inpatient processes.
  • Timeline is critical: Don’t interfere with patient visits, office workflow or practice workflow.
  • Anticipate the need to work closely with the compliance officer at the hospital or health system level.
  • Make sure physician leadership is on board and knows “why we’re doing this.”
  • Educate clinicians and practice administrators on the repercussions of incorrect code selection under various value-based programs such as Medicare's Merit-based Incentive Payment System and Alternative Payment Models.

Measuring outpatient CDI success

Data from the first five months of Christiana Care’s outpatient CDI program reveal that its query response rate is rising. “We started with a query response rate of 34 percent in November and have seen that rise as high as 69 percent over the course of our program so far,” Frosch says. A log of coding documentation feedback is given to physicians and their office managers, along with support via office visits and calls to promote ongoing improvements.

The impact Christiana Care’s outpatient CDI program has had on physicians has been a big benefit to the organization. “We’ve seen a huge win there,” says Frosch. “Now our physicians call us with questions and to clarify code assignments. Physicians want and need help with choosing the right codes. That’s where we come in and can be the superheroes for their practice.”

Pam Hess, M.A., RHIA, CCS, CDIP, CPC, is managing director of clinical documentation improvement at Himagine Solutions in Tampa, Fla.

The opinions expressed by the author do not necessarily reflect the policy of the American Hospital Association.