The conundrums of starting an outpatient CDI program

Outpatient clinical documentation integrity (CDI) programs are essential to ensuring accurate, complete and compliant documentation of patient encounters. Thorough documentation by a physician improves patient care and ensures that physicians and organizations receive appropriate reimbursement. Being able to measure the effectiveness of an outpatient CDI program is vital to ongoing operations. 

How do you classify outpatient CDI?

There are many different interpretations of outpatient CDI programs, how they operate and their overall program goals.  What does outpatient CDI mean to you? Outpatient CDI is not a one-size-fits-all, and, depending on an organization’s need, an outpatient CDI program can be established in any of these settings:

• Emergency department 
• Same day surgery 
• Observation
• Ancillary services
• Ambulatory (physician) clinics
• Ambulatory surgery centers (ASCs)

How do you determine where to build an outpatient CDI program?

This is a tough question to answer because it must be based on the needs of the organization and the focus of your program. Ask yourself what outpatient setting has opportunities for improvement.  When determining the setting, an organization should keep in mind the program’s overall goal, the type of data to collect, and how the impact and success of the outpatient CDI program will be measured. Additional components include: How will you staff your program? What type of review will you perform to collect the data: prospective, concurrent or retrospective?  Building an outpatient CDI program is not an easy task, and there are many variables to consider.  

How do you measure the performance of the program to monitor success? 

Remember, when determining where to start your outpatient CDI program you have to decide on the type of data to be collected and the overall focus of your program. Metrics should be built around the data and organization goals and can vary depending on the setting of your outpatient CDI program and the type of reviews being performed. 

Common measurable areas of focus are:

• Query rates
• Query response rates
• Denial rates
• Hierarchical condition category (HCC) capture rate
• Coding variance
• Reimbursement impact
• Quality
• Productivity

Lastly, it is especially important to educate key stakeholders about how an outpatient CDI program operates differently than an inpatient CDI program. There are several differences between outpatient and inpatient services, such as different reimbursement systems, the cost of services rendered, the coding guidelines, the measurable metrics, the type of documentation reviewed and timing for return on investment. 

Review our recent webinars to learn more about opportunities for building an outpatient CDI program.

Nichole Soderquist, MBA, RHIA, CDIP, CCDS-O, CCS, is ambulatory services consulting manager, consulting services at Solventum.

Sue Belley, RHIA, is senior manager, compliance and audit services at Solventum.