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The Top 3 Challenges in Outpatient CDI

Outpatient clinical documentation improvement (CDI) is in its infancy. As our experience grows in this arena, we gain new insights and move closer to nationally recognized best practices. But meanwhile, we face some challenges.

The Top 3 Challenges in Outpatient CDI:

  1. Industry Standards are Not Yet Formed – In the coming years, processes and metrics will continue to emerge. But at this point, we don’t have nationally recognized standards. UASI has identified ideal ratios for assessments and audits, based on our experience.
  2. Best Practices Vary Widely – Some organizations conduct pre-reviews, post-reviews, and physician queries, but again there aren’t standard approaches that outpatient CDI specialists regularly follow. UASI has identified protocols to address our clients’ specific outpatient service focus areas.
  3. The Outpatient CDS Role is Unclear – Credentials, skill set, and experience are up for debate for the role of the outpatient CDS. As needs are discovered and regular practices emerge, this job description will become more consistent. UASI has defined skill sets for outpatient CDI specialists that correlate with various outpatient focus areas.

Although outpatient CDI is still evolving, UASI has identified some approaches to improve documentation and reporting in the outpatient clinic health record. Here are 3 results that we consistently identify as actionable findings:

  1. Documentation present to support additional diagnoses that were not reported on a claim
  2. Diagnosis codes reported on a claim that are not supported by health record documentation
  3. Use of unspecified diagnosis codes when documentation provides more specificity

If you still have questions about outpatient CDI, register for our next webinar on February 24, 2021. The following questions will be answered by Staci Josten, Director of CDI at UASI.

  1. Should you do pre-reviews or post reviews of the patient encounter?
  2. Who should do the reviews- what qualifications do you want your outpatient CDS to have?
  3. What will your query or recommendation process look like?
  4. What types of patients and records should you review?
  5. What will success look like (increased provider knowledge, more accurate RAF score, etc.)?

Need help with establishing your outpatient CDI program? UASI has helped our clients across the country establish or maintain quality CDI programs. Contact us now at to get started.