Making the case for outpatient CDI in the emergency department.

The emergency department (ED) is often the first place a patient is seen before being transferred to the inpatient setting, and is an important part of any hospital inpatient stay. The September 2021 Association of Clinical Documentation Integrity Specialists (ACDIS) annual survey, conducted “to gain insight into the state of the industry,” included several questions about outpatient CDI. Regarding the emergency department setting, 16.47 percent of respondents said they reviewed emergency department services. Some of the noted reasons for the ED focus were patient status, medical necessity, and denials prevention.

An outpatient clinical documentation integrity (CDI) effort in the ED must begin with a thorough assessment to identify areas of opportunities, along with prioritization of program efforts. To be impactful in your efforts and utilize your resources effectively, it is important to think big, but start small. 

Inpatient CDI programs often overlook documentation in the ED during concurrent record review. Gaps in documentation for admitted patients treated in the ED can result in medical necessity denials, short stay denials, inaccurate MS-DRG assignment, and negative impact on quality measures. A retrospective review of inpatient denial trends can reveal gaps in ED provider documentation contributing to denials. Short inpatient hospital stays, as one example, often result in denial of services. Performing a concurrent review of ED documentation and collaborating with the clinical areas of the ED, case management, and utilization review on next-level-of-care criteria can result in an increased accuracy of predicting patient status for the next level of care, reduced denials, and revenue leakage. Assessing admissions for accurate present-on-admission (POA) assignment for evolving conditions such as sepsis, pulmonary embolisms, DVTs, pressure ulcers, and catheter-associated infections can also have a big impact on quality reporting. POA is defined as conditions present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including the ED, observation, and outpatient surgery, are all considered as present on admission.

For patients discharged from the ED, gaps in documentation can result in lost revenue and denied services. One area of focus for ED outpatient CDI to consider is the facility evaluation and maintenance (E&M) level of service. When assessing ED-discharged encounters, I strongly recommend an assessment of the criteria used for facility E&M level assignment. The facility E&M level of service should reflect the volume and intensity of resources utilized by the hospital to provide patient care in the ED.

As part of your assessment on E&M facility level assignment, begin by researching the recommended criteria from the Centers for Medicare & Medicaid Services (CMS), the American College of Emergency Physicians (ACEP), and others to fully understand the intent of accurate assignment. Facility E&M assignment dates to the beginning of the Outpatient Prospective Payment System (OPPS) in 2000.

Next, analyze your facility E&M bell curve distribution against national E&M level distribution data. Once you have this information, interview parties involved to determine how your facility assigns E&M level of service, then conduct a record review to assess accuracy of assignment against your facility criteria to help determine if the criteria used is contributing to over- or under-payment for ED services.   

Outpatient CDI in the emergency department, just like outpatient CDI overall, is unique to each healthcare organization. When measuring success of your efforts, it starts with the initial assessment and the steps taken to improve the opportunities identified. Think big, but start small! You can’t tackle everything at once, but you can start somewhere – and have a positive impact on documentation integrity in the ED.

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