More care has shifted to the outpatient setting over the past several years. This has spurred a motivation for healthcare providers to focus on outpatient clinical documentation improvement (CDI) programs. Outpatient CDI programs are growing and parameters of the field are becoming more clearly defined. When looking to create an outpatient CDI program, follow these 7 essential steps:

#1: Begin with data acquisition and assessment

Just as you would do with any new program, gather data for your new outpatient CDI endeavor. Make sure you consider:

  • your denial rates
  • your RAF scores and how they compare to area clinics
  • in what areas your organization received low-quality scores
  • reimbursement by health plans

patient with doctor in office

You’ll also want to conduct a minimum 1-year review of patient codes and HCC data. A baseline assessment of documentation is necessary before you can set program priorities. From here, you can chart areas of potential growth, insights that lead to improvements, and potential upcoming opportunities.

#2: Define your scope

After your initial data analysis and charting of goals, it’s time to define your scope. Some providers classify all hospital-based care aside from inpatient settings as CDI. On the other hand, some physician practice offices and facilities limit it. It’s important to understand which services specifically fall into the outpatient footprint to create better programs.

#3: Determine your organization’s needs 

Each provider has unique needs that will determine CDI program design. Consider these questions as you personalize your OP CDI program implementation:

  • Does your organization provide any Medicare Advantage programs?
  • What is the volume of denials your organization receives for medical necessity of patient status?
  • Likewise, what is the volume of medical necessity denial for instances of outpatient surgical care?
  • Are value-based payment programs a part of your organization’s care plan?

#4: Determine your ROI goals 

Implementation of quality OP CDI programs can be threatened when organizations do not first properly establish target goals and indicators. This initial step can be challenging. However, building the program around key strategic goals can help focus and tailor your OP CDI program to be more effective and easier to implement.

There are many different ways to measure return on investment (ROI). Many organizations base success around changes in RAF scores. However, this can be difficult. There is generally a time delay (nearly 6 months in some cases) to see the financial impact of RAF scores. It’s best to use RAF as one indicator, but other essentials may include reduced denial rates and reduced re-work.

Experienced OP CDI specialists can be a benefit to your organization throughout implementation and beyond. They can help you better identify measures of success and where improvements need to be made.

#5: Understand the challenges of OP CDI implementation

OP CDI is markedly different from inpatient CDI and may require additional staff and personnel training. One of the biggest differences is that outpatient visits are much shorter compared to inpatient. While care providers may have several days or even weeks to review documentation, outpatient visits typically last between 10 to 45 minutes. This makes clinical specialist documentation review more difficult.

Program designers need to structure CDI to ensure physical documentation is reviewed by prioritization of risk score and gaps. Moreover, administrators need to ensure documentation accurately reflects procedures and is descriptive including proper coding and claim submission from the start. Productivity is the backbone of successful outpatient CDI.

outpatient surgery

#6: Ensure your physicians are prepared

Before implementation, ensure physicians are informed and motivated to facilitate your new program. Its success depends on quick responses from physicians to your OP CDI staff.

It’s your organization’s responsibility to empower physicians to document correctly. This helps them maximize their time with patients. Make sure your clinical team understands the importance of CDI, chart reviews, and accurate documentation. Provide the team with feedback channels and highly skilled educators so they understand documentation protocol.

#7: Review, review, review

OP CDI is evolving. Your institution’s needs and challenges may have it headed into uncharted territory. It’s crucial to create both inpatient and outpatient CDI programs that facilitate sustainable long-term revenue models. To do so requires consistent review.

In the initial stages of implementation, set up a committee of stakeholders. This committee should establish an approach and targeted goals. It should also be ready for consistent review meetings and for goals to evolve. Speak with physicians and OP CDI staff to hear what’s working and what might need to be tweaked. You’ll see progress in time, but not without keeping a sharp eye out in the beginning.

We’re here to empower you

Harmony Healthcare’s Clinical Documentation Improvement solutions support your organization with interim expertise to optimize reimbursements and prevent future denials.

Discover how our solutions can help your organization:

  • improve clinical documentation to mitigate lost revenue and retain future revenues
  • identify clinical documentation and revenue integrity opportunities for optimal reimbursement
  • streamline the CDI process with robust analytics and automated worklist triage for improved efficiencies and optimized reimbursements

See how the right service partner can provide a better solution for your staffing needs here.

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