There has been a wide array of discussion through published articles, forums, webinars, and meetings about the topic of outpatient clinical documentation improvement (CDI) programs. Outpatient CDI is receiving much attention and experiencing traction in the healthcare industry due to providers coming to terms with the fact that documentation truly matters from a financial perspective, with Medicare Advantage and now Medicare coming into play through their value-based payment models utilizing Hierarchical Condition Categories (HCCs) as factor in adjusting provider payments. HCCs are a series of chronic clinical conditions that affect the complexity of a patient and are utilized to calculate a risk score applied to each patient, specifically by calculating monthly capitated payments to the Medicare Advantage third-party payors. Specific clinical conditions impacting calculation of the risk adjustment factor include chronic kidney disease, stage V, diabetes with complications, congestive heart failure, and chronic obstructive pulmonary disease, to name just a few diagnoses.

There are two types of HCCs:

  1. The CMS-HCC model is used by the Centers for Medicare & Medicaid Services (CMS) for risk adjustment in the Medicare Advantage program; it addresses a predominately elderly population (65 and over, or those otherwise qualifying for Medicare). Within this framework, the CMS-RxHCC is used separately to address Medicare Part D.
  2. The HSS-HCC model is maintained by the U.S. Department of Health and Human Services (HHS) to address commercial payor populations and covers all ages.

Both models employ a risk adjustment score to predict future healthcare costs for plan enrollees. According to the CMS website, “risk adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk-adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Risk adjustment is used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee. Risk scores measure individual beneficiaries’ relative risk, and risk scores are used to adjust payments for each beneficiary’s expected expenditures. By risk-adjusting plan bids, CMS is able to use standardized bids as base payments to plans.”

Focusing Upon HCCs: Is This the “Right” Approach?

The primary focus of most hospital CDI initiatives is on capturing CCs/MCCs and principal diagnosis selection achieved through the query process, a reactionary, transactional, repetitive approach purported to be clinical documentation improvement. This approach to CDI does not in and of itself constitute true clinical documentation improvement; little in the way of quality and completeness in clinical documentation is achieved aside from capture of diagnoses directly impacting case-mix increase and ultimate reimbursement. Unfortunately, hospitals and healthcare systems are proceeding down this path, as efforts are underway to organize and establish outpatient CDI programs. Begin a discussion about outpatient CDI, and undoubtedly the topic of HCCs comes up. Outpatient CDI is much, much more than chasing down and capturing diagnoses with the sole intent of boosting revenue and risk adjustment scores. While I am certainly not averse to hospitals being reimbursed fairly and equitably for their care provided, given the increasing costs to operate a business, it is the direction and processes followed in these developing outpatient CDI programs to which I take exception. We must not simply emulate ill-conceived inpatient CDI processes masquerading as documentation improvement and instead adapt to the outpatient arena.

Outpatient CDI: What Should the Focus Really Be?

The major focus of outpatient CDI must center on what the record stands for and represents, that is, a tool for communication of patient care beyond just recording of diagnoses. Clinical documentation serves to track a patient’s condition and communicate the author’s actions and thoughts to other members of the care team. The medical record is used by physicians to record their findings and actions, and as a vehicle to communicate with other physicians who might care for the patient in the future. (See Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper from the American College of Physicians-Annals of Internal Medicine online at William Osler, a founding father of John Hopkins School of Medicine and the first form of “modern medicine” practiced outside the classroom residency training program said it nicely with the following: “Observe, record, tabulate, communicate.”

Rather than counterintuitively and counterproductively expending energy on merely securing a diagnosis representing HCCs, CDI efforts should be focused on promoting, advocating for, and achieving documentation that best communicates the quality patient care delivered. What am I referring to when saying “documentation that best communicates?” Attributes of documentation that communicates consists of clearness, conciseness, and consistency. More documentation is not necessarily better documentation. Documentation is considered complete if it contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results of treatment, and facilitate continuity of care. A medical record is sufficiently detailed and organized if it enables the responsible practitioner to provide continuing care, determine later what the patient’s condition was at a specified time, and review diagnostic/therapeutic services performed and the patient’s response to treatment.

Achieving Complete and Accurate Clinical Documentation

Affecting measurable, reliable, and valid improvement in outpatient documentation starts in the physician’s office, given the fact that all outpatient services provided in the hospital setting (aside from emergency room services and screening mammograms) emanate from the physician’s office. Physician orders for all hospital-related services begin in the physician’s office, driving medical necessity and coverage of services rendered in the hospital outpatient setting. The diagnosis on the order is not the end-all and be-all; instead, the clinical information, clinical facts, and context described and shown in the documentation is paramount in support of the diagnosis, plan of care, and further patient workup scheduled.

The physician has a duty and responsibility to the patient as well as his or her business of medicine to incorporate complete and accurate charting of every patient encounter. Effectiveness in continuity of care, patient care handoff, the ability of the patient to receive care within the spectrum of their insurance coverage with reduced financial hassle, and physician demonstration and adherence to efficiencies in the practice of medicine – defined as ordering and providing a level of service that is sufficient but not excessive given the patient’s health status – is totally dependent upon the quality and completeness of documentation, beginning with the patient’s chief complaint and recorded history of present illness. This process continues with the physical exam and culminates with the diagnostic assessment and plan of care, including reasonable representation of diagnostic reasoning, medical problem-solving, medical decision-making and general thought processes.

Beginning the Journey in Outpatient CDI

Before embarking on an outpatient CDI initiative, the imperative of defining and outlining the goals and objectives of the program must be stressed and incorporated into all elements of the program, including structure, process, and outcomes. First and foremost, CDI processes that facilitate and drive documentation improvement efforts must be established, and the temptation to focus upon the short-term gain associated with HCC diagnosis reporting should be avoided.

Take the time to construct a solid foundation for success in your program by planning, organizing, and designing a well-thought-out program driving long-term success.

In my next article, I will lay out key elements of an outpatient CDI program to set you on the right course.

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