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Ten Steps to Create a Successful Outpatient CDI Program

Key Steps to Successfully Implement Outpatient CDI in a Physician Practice

Outpatient clinical documentation improvement (CDI) is a critical topic among those involved in mid-revenue cycle processes. It can sometimes be a challenge deciding where and how to get started. We’ve simplified the process by outlining our recommendations.

1. Gather data and assess the current state

Before you begin, it is crucial to understand where your pain points are in your physician office practice. For example, clinic administrators’ concerns may center around high denial rates, RAF scores that are lower than area clinics, low-quality scores, and/or reimbursement from risk-adjusted health plans. Understanding what specific areas of opportunity to evaluate will help focus your Physician Practice CDI Program.

Once pain points are identified, determine whether the Physician Practice CDI Program assessment can be effectively and efficiently managed internally or if an outside consultant is more appropriate. The assessment should include a review of current documentation processes and a two-year review of patient HCC data and codes. The assessment should also include an initial audit, which is critical to help understand baseline documentation issues and guide program priorities. Select patients based on specific data-driven criteria. This helps identify areas of success, insights into areas needing improvement, and understanding where the greatest opportunities are to make the largest impact.

2. Define program scope and approach

Define and align. Ensure your team is working towards a shared vision for the program and understands how to utilize your Physician Practice CDI resources. Because patient volumes can be significant, it is critical to determine how you’ll get started, how to utilize resources efficiently and how to set realistic expectations.

Align your particular area of focus and consider starting with high volume or high revenue patients or members of specific health plans. Or, consider primary care providers and expand to specialties once processes are refined, and benefits demonstrated. External consultants offer insights and analytical approaches to help target scheduled patients for pre- and/or post-visit review.

3. Outline program goals and ongoing data needs

Understanding the end goal will help determine where to begin. Set clear, measurable goals. For example, based on the results of the baseline audit, your goal may be to increase raw RAF scores by 10% through accurate HCC capture. Therefore, capture pre- and post-RAF score data on an ongoing basis. Also, you may set a goal to complete a follow-up audit several months after implementing the program to compare RAF score changes.

Before getting started, determine data needs and reports necessary to accomplish set goals. Collecting RAF scores for each provider and clinic is beneficial, but RAF scores can be difficult to obtain. Work with your contract office to identify payers administering managed health care plans. You may need to insist that payers share RAF scores with you. Also, you may need to calculate raw RAF scores internally, since there may be a significant lag time in obtaining RAF data from payers. External consultants have tools to calculate and compare raw RAF scores.

Explore reporting mechanisms in your EMR and practice management systems. Based on the priorities determined, it may be beneficial to focus on patients with specific chronic conditions. Can you leverage your systems to identify these cases? For example, can you obtain a report on all patients with unspecified diabetes codes and subsequently obtain a follow-up report to identify improvement in the specificity of diabetes coding attributable to the CDI Program? Look for functionality in your EMR to identify patients with chronic conditions.

It is beneficial to assign a data analyst to your CDI team. This person can be instrumental in obtaining and tracking EMR data.

4. Determine return on investment

The adoption of a quality outpatient CDI program is often stalled when practices neglect to establish the goals and program measurements up front. This can be a challenging step because goals and measurements vary depending on program focus. However, gaining administrative support for program development will be easier if the strategic goals are in place prior to development.

In a physician practice with patient groups in risk-adjustment payment models, one of the best ways to quantify return on investment (ROI) is to measure changes in RAF scores. However, unlike the inpatient setting (where we can easily see what a query does to move the DRG payment on a case in real-time) there is typically lag-time in projecting the financial impact of the RAF score. Though RAF scores prospectively determine payment (this year’s RAF score determines next year’s payment), the RAF score results are typically communicated six months after the fact — much too late in the process to address the documentation on those patients. It’s not uncommon for a physician practice to realize they need a Physician Practice CDI Program when they are notified of a significant drop in their per member per month (PMPM) rate. At that point, it may be too late to recover until the next rate adjustment period.

Depending on the focus of the CDI Program, ROI may also be demonstrated by reduced denials, increased accuracy in procedure coding (e.g., E/M levels or time-based codes), capture of missed office procedures, and/or reduced re-work and streamlined documentation and coding processes. An experienced consultant works to identify the greatest area of opportunity and success.

5. Develop program staffing infrastructure

Once the Physician Practice CDI Program focus and scope is established, goals are set and administrative buy-in has been obtained the next step is defined infrastructure. This includes reporting mechanisms, staff qualifications, and staffing levels specific to your organization.

Your CDI specialist may report to a CDI Manager or to the Clinic Manager, HIM Director, Quality Department or CFO. The structure is dependent on your practice. However, we recommend the leader has advanced knowledge of the healthcare industry’s complex quality and reporting initiatives as well as HCC’s and risk-adjusted payment methodologies. The leader should be aligned with the CDI program goals, understand coding and be a collaborator, mentor, and educator of staff within the clinic.

Determining the qualifications of the CDI staff can be difficult. Since Outpatient CDI initiatives are relatively new, industry best practice standards, including staff ratios, qualifications, and staff credentials have yet to emerge. However, based on our experience, there are key CDI staff skills necessary to ensure success. These include familiarity with medical records review and the ability to recognize documentation gaps, understanding HCC’s impact, excellent communication skills to effectively interact with physicians and office staff, and a general knowledge of coding. Because both coding and clinical professionals may be involved in the program, consider what tasks you want accomplished and then determine the skills necessary to achieve your goals. Let this be a guide to establish roles and evaluate the level of expertise necessary to be successful — whether it’s a nurse (e.g. RN, LPN, CCDS, CDIP) and/or HIM/coding professional (e.g. RHIA, RHIT, CCS, CCS-P, CPC). You should also consider whether you will actively seek staff with emerging specialty credentials (e.g. CRC, CDEO).

Depending on the number of clinics and total patient population served, your staff level should be adjusted to meet those demands. Because industry best practices have not been established, we recommend starting your program with two or three trusted staff and determine appropriate productivity expectations and staffing levels based on their experience and early results.

6. Define initial workflow and processes

UASI recommends clients follow best practices; define, track, measure and adjust. Not only is it important to define project scope, it is also important to define initial workflow and establish processes and procedures. Building a process from scratch can be daunting. We caution clients to resist the urge to mirror inpatient CDI processes. Instead, focus on your outpatient CDI program goals and the documentation priorities you’ve identified. Create mechanisms to insert documentation improvement within the clinic’s existing workflow. It’s a team effort, so make sure you involve others, particularly physicians, coders and others involved in documenting and billing clinic visits. Consider these questions when developing processes:

  • Will you review health records before scheduled patient visits, concurrently or retrospectively?
  • Will you query providers and if so, how will you communicate the queries? Will you track queries and confirm health record documentation reflects the query response?
  • Who provides feedback to providers?
  • What feedback will you share with providers?
  • Who and how will you educate providers?
  • Can you leverage EMR functionality and if so, to what extent?

It is important to remain flexible and encourage creativity among the CDI team members. Recognize the need to start somewhere and put a process in place that will guide improvement along the way.

7. Communicate and educate

Who are your key stakeholders? Understanding who needs to know about the new CDI program is crucial. Once determined, begin outlining a comprehensive communication plan to ensure buy-in from stakeholders. The communication plan should include program goals, messaging to each audience, timelines, progress sharing and expected outcomes — how will this impact the stakeholder?

Providers and stakeholders will require a thorough education and communication plan. This is key to ensure providers understand the impact and value of specificity in accurate documentation. Understanding this will help motivate cooperation in implementing and carrying out CDI processes. Keep in mind that collaboration is key. Seek input to refine improvement processes and then clearly define expectations. For example, what are the specific steps to answer a documentation query? Where should an answer to a query be recorded? Is there an escalation process if queries are not answered or if provider documentation is conflicting?

Providers are busy. To ensure engagement, keep communication and education brief and provide real-life examples, preferably from their chart notes. Most providers have little time for email, therefore identify creative ways to disseminate information — whether through existing meetings or training and always communicate how it will personally benefit the provider. Ongoing communication with providers should include status updates, successes, opportunities, and comparative data.

8. Set performance expectations

Setting clear staff performance expectations at the onset keeps everyone working towards the same goals. We see program success when this occurs. Identify expectations, communicate those expectations, evaluate throughout the process, measure and adjust when necessary.

Mapping out productivity and quality performance expectations can be a challenge. Conducting initial time studies can help develop realistic productivity goals. For example, determine the daily or weekly chart reviews completed, the average query rate, physician response rate, number of physician interactions and/or provider education delivered. Peer review can be a useful quality mechanism. Successful programs develop initial performance goals and adjust those based on experience.

9. Monitor, track and measure

Executives and key stakeholders understand ROI. Keep this in mind as you monitor, track and document the success of your program. Identify both process-oriented and outcome-oriented measures. You will need a tool that allows you to both record specific documentation improvement efforts at the case level and analyze this information to identify trends and evaluate outcomes. This could include individual productivity as well as trends in identified documentation gaps. Results of the CDI Program might be analyzed for actual improvements (e.g., code corrections/claims re-submissions) and/or potential improvements (e.g. potential corrections/provider queries).

As you establish and refine staff performance expectations, concomitantly establish and refine the metrics to monitor and track performance. At a minimum, outpatient CDI performance metrics should include productivity of CDI staff, number of documentation gaps addressed, and provider responses. Also, it is valuable to track metrics by provider and/or specialty. For example, tracking individual provider documentation gaps over time can be helpful to gauge provider’s support of the CDI process.

10. Ongoing program evaluation

Once you’ve successfully implemented a Physician Practice CDI Program, continue to evaluate the impact of the program, refine program goals and continuously adjust your approach to respond to evolving insights and changing priorities. Evaluate CDI processes to identify opportunities to gain efficiencies over time. Determine if expanding to other specialties or including more patient populations may be warranted. Complete periodic audits to verify accuracy and consistency.

UASI consultants are experts in implementing and effectively managing outpatient CDI programs. Wherever you are on the path to creating a successful Physician Practice CDI Program, UASI can be your partner. Contact us today by calling 800.526.0594.


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Staci Josten, BSN, RN, CCDS
Senior Manager, CDI & UR Staffing Services, UASI

Tara Bell, MSN, RN, CCDS, CCM
Manager, CDI & UR Staffing Services, UASI

Lisa Farhar, RN, MBA, MSN, CCDS
CDI Supervisor, UASI