Outpatient clinical documentation improvement (CDI) encompasses a variety of settings, including ambulatory and outpatient departments, such as critical care, rehabilitation outpatient centers, ambulatory services care, same-day surgery centers, ancillary services, diagnostic imaging centers, cardiac catheterization centers, behavioral health, gastrointestinal and chemotherapy, and radiation therapy centers. Outpatient CDI also applies to professional services in physician practices and centers, family medicine, and primary care providers with a heavy focus on delivering value-based care, which is only expected to increase through at least 2028. As healthcare organizations increasingly provide care in these settings, understanding the differences between inpatient and outpatient CDI programs is increasingly important, as the variability between how each setting operates creates distinct challenges.
Inpatient CDI primarily focuses on the accuracy and improvement of diagnosis-related group (DRG) codes within the case mix index (CMI), comorbidity capture, patient safety indicators, and quality measures. Concurrent review includes a two-night minimum for a patient's stay, which allows time to address queries and other adjustments prior to discharge. On the other hand, outpatient CDI involves prospective reviews for coding for outpatient prospective payment systems, payer-specific requirements, medical necessity, and ambulatory payment classifications (APCs), as well as retrospective reviews for improvement opportunities.
Outpatient CDI teams face several challenges, including staffing limitations, the fast pace of encounters, compliance with concurrent and prospective queries and reviews, and the blurring line between facility charging and provider billing. These challenges necessitate the use of CDI tools featuring artificial intelligence (AI) and automation to help prioritize caseloads, auto-generate queries, and improve productivity.
To establish an effective outpatient CDI program, organizations can build upon existing inpatient CDI processes and develop robust chart review and communication query processes. It is crucial to evaluate Medicare Advantage contracts to ensure alignment with the payer contracts and specific requirements, define program scope, and use analytics to prioritize areas for improvement. Metrics should be carefully chosen to demonstrate ROI and align with key objectives, such as risk adjustment factor (RAF) scoring improvements.
Computer-assisted CDI software plays a vital role in improving performance and ensuring outpatient CDI by increasing productivity, leveraging natural language processing (NLP) and machine learning to enhance recognition and annotation within the documentation, and auto-suggesting relevant codes. Integration with various electronic health records (EHRs) and practice management tools enables the consolidation of data from multiple sources for comprehensive documentation, coding, and reporting. Collaboration tools, smart lists (dynamic work queues), robust reporting, and business intelligence capabilities are also essential for effective outpatient CDI.
Outpatient clinical documentation improvement is an integral part of healthcare organizations’ transition toward delivering care in ambulatory and outpatient settings. By focusing on accurate code assignment, appropriate reimbursement, quality reporting, and minimizing overpayments, healthcare providers can enhance patient care, improve financial outcomes, and ensure compliance to optimize outpatient CDI programs.
Watch the webinar, Outpatient CDI: Ensuring accurate and complete documentation to learn more, and contact us for assistance in addressing and resolving outpatient CDI challenges.
Eric McGuire, CRCR, PgMP, PMP, LSSGB
