CDI – It’s No Longer Just About Inpatient Services

Many hospitals around the country have implemented clinical documentation improvement (CDI) programs to ensure that inpatient medical record documentation is accurate and can be seamlessly converted into billing (CPT and DRG) and diagnostic (ICD-10) codes. More recently, CDI programs are being developed to assist providers with documentation requirements in the ambulatory space (physician practices, emergency departments, hospital outpatient departments, etc.). An ambulatory CDI program, like inpatient CDI programs, involves looking at the documentation used to support billing (especially E&M or evaluation and management codes) and diagnosis codes (ICD-10). However, with the advent of value-based reimbursement models (MIPS, APMs, MA, Bundles, etc.) from both the commercial and government payers, CDI in ambulatory settings also must focus on risk adjustment coding that is used to level set quality and cost measures used in these novel payment programs.

The most common risk-adjustment methodology is the model used by CMS for programs such as Medicare Advantage. In this model, hierarchical clinical conditions (HCCs), which are diagnostic codes that signify risk and are used to develop risk adjustment factor (RAF) scores, must be addressed by providers on a recurring basis (annually) so that they can be used to adjust performance metrics and provide for a fair comparison between individual providers. As an example, a provider who is being judged on the quality and costs of the diabetic care he or she is providing for their patients will need to document carefully the HCCs present in their diabetic patient population so that their performance can be compared accurately with that of another physician. A provider, for instance, whose average RAF score within their diabetic population is 6 would not be expected to perform as well on quality or cost measures as someone whose average RAF score is 2. Therefore, their scores would need to be adjusted to account for the higher complexity and risk associated with their patient population.

Unfortunately, many providers are not familiar with risk adjustment coding and the documentation requirements around HCC capture or RAF score calculations. Going forward, this lack of knowledge must change for individual providers and provider groups to optimize their performance in value-based reimbursement plans.

A good place to start would be a risk adjustment coding audit that retrospectively looks at the HCC capture rate, gaps in HCC documentation, and average RAF scores. This data can not only quantify the need for more attention to the ambulatory CDI process, but can also help risk stratify patients who might benefit from services such as annual wellness exams, chronic care management programs, transitional care management, or even end-of-life care. Indeed, population health management starts with a solid understanding of the target population’s risk. This step is a good place to begin as more and more organizations venture into (or are pulled into) population health management programs.

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