Outpatient CDI information

Would anyone have information about their outpatient CDI program they would be willing to share?  

For instance, what areas in the facility are you reviewing as part of you outpatient CDI (ED, Same day surgery, hospital owned physician practices)??  

Does outpatient CDI include those patient in the hospital who are currently observation status (occupying a bed)?  

If your facility does not have outpatient CDI, do your inpatient CDI's review those patient who are in observation status? 

We currently only review inpatients (all payers, self pay).

Thanks in advance

LeeAnn

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  • Hi LeeAnn,

    I started down the OP path about two years ago. All of these areas, as you know, are considered OP but I had to determine where to start. I did that by looking at a lot of data (denial, payor contracts, etc.). Our facility owned physician group had contracts with Medicare Advantage payers, and there was a bonus opportunity there if we improved our RAF score. This is where we found our biggest opportunity right off the bat. We are now part of an ACO and participate in a MSSP. So there is significant opportunity. Our OP CDI program is expanding to the larger medical group this summer. We started out small in one region with just family medicine and internal medicine physicians and then expanded it to Cardiology and plan on expanding further to endo and neuro. We have shifted from reviewing MA patients to Straight Medicare, and our other ACO products.

  • Thanks for your info...  Does your inpatient CDI review the observation patients in house?  We currently employ a CT surgeon and soon adding pulmonologists..


  • I am very interested in learning about OP CDI.  Some great information here.  I'm wondering where you got the data to review? Denial, payor contracts, etc?  Did that come your Quality Department?  Thanks!
  • I am very interested in learning about OP CDI.  Some great information here.  I'm wondering where you got the data to review? Denial, payor contracts, etc?  Did that come your Quality Department?  Thanks!

    Karen.schaefer@stjoe.org
  • Our outpatient program started by using quality data given to us from our ACO. Given that data and the opportunity we saw, we started with primary care physician practices focusing on HCC's and gap closures. We also audit the coding department as well at 100% on our ACO payer population (Medicare advantage plans). We have more recently started working with our ACO and working with the offices on the education and auditing of medicare wellness visits and transition of care visits. We also have an RN in the surgical area that focus's on status C cases. And another RN in the ER who works with E/M leveling and infusion/medication documentation. 
  • longl1 said:
    Thanks for your info...  Does your inpatient CDI review the observation patients in house?  We currently employ a CT surgeon and soon adding pulmonologists..



    We currently do not review observation charts. We specifically focus on our primary care physician group and cardiology physician group.
    ssipunu said:

    Hi LeeAnn,

    I started down the OP path about two years ago. All of these areas, as you know, are considered OP but I had to determine where to start. I did that by looking at a lot of data (denial, payor contracts, etc.). Our facility owned physician group had contracts with Medicare Advantage payers, and there was a bonus opportunity there if we improved our RAF score. This is where we found our biggest opportunity right off the bat. We are now part of an ACO and participate in a MSSP. So there is significant opportunity. Our OP CDI program is expanding to the larger medical group this summer. We started out small in one region with just family medicine and internal medicine physicians and then expanded it to Cardiology and plan on expanding further to endo and neuro. We have shifted from reviewing MA patients to Straight Medicare, and our other ACO products.


  • We obtained the data from payor contracts and our quality department. I did comb through denial data to see where we had denials based on ICD-10 CM codes as well.



    I am very interested in learning about OP CDI.  Some great information here.  I'm wondering where you got the data to review? Denial, payor contracts, etc?  Did that come your Quality Department?  Thanks!


  • Hello,

    Are any of you working in Ambulatory/OP CDI with physician practices focusing on HCC capture in at-risk contracts who would be willing to share some information about your program?


    Specifically looking for a model to help launch this initiative and would like to share how others have made a difference.

    How many lives/patients in your risk contracts, MSSP?

    What was your baseline RAF? Improvements seen?

    Program model/Staffing/Approach for implementation

    Productivity

    Tools/Vendors used


    Appreciate any information you are willing to share and if you would be so kind, I would be happy to set up a brief call with you to discuss.


    Thank you in advance,

    Kris Kegarise

  • Our program model is to have a nurse do a prospective chart review and a coder who is CRC certified and HCC coding trained do a prospective and retrospective review. We cover only Medicare lives right now due to the size of our health system. Originally, we started with only Primary Care in one region and were able to cover Medicare Advantage and Medicare. We then moved on to reviewing Cardiologist visits. The goal was to move into specialists reviews, but we merged with a large health system and have expanded to primary care only at this point through the entire system.

  • Hi there,


    Do you have any data on productivity for nurses/coders? How are you tracking progress or that the program is doing well? RAF scores? Capture Rate?

  • edited December 2020

    @ssipunu


    We track our data manually on spreadsheets. Each HCC diagnosis that CDI has shown a direct impact on is tracked and then when it goes out on a claim, we take credit for the RAF of that diagnosis. Then each month that data is gathered and presented to our C-suite to show shared savings progress.

  • I will need to present a monthly excel report to C-suite of progress with our ACO MSSP HCC diagnosis/RAF captured per provider - does anyone have a specific template they can share so that I have an idea of how it can be presented to C-suite as I am new to this area? Thank you

  • Would you be able to share a sample template of your worksheet if it is a successful process for you? Thank you

  • Our Healthcare System is currently only using CDI for Inpatient record review.

    Recently, a provider asked me how Inpatient CDI reviews impacted the ACO and its revenue, and if there was any correlation between the work done in the inpatient setting and the outpatient ACO world.

    • Inpatient captures MCC/CC for MS DRG, and Outpatient looks at HCCs, are the two relating or influencing one another at all?
    • Does IP CDI review assist or hurt the bottom line for ACOs?

    My recommendation to the provider was to continue documenting to the highest specificity appropriate and to ensure good documentation.

    Any tips or explanations are very welcome! Thanks in advance!

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