Health Information Management

Outpatient CDI efforts offer documentation opportunities

JustCoding News: Outpatient, February 22, 2012

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With the advent of Medicare Administrative Contractors (MAC), which review both Part A (hospital) and Part B (physician) billing, payers are now looking to ensure that physician and facility billing match, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDIS, CCDS, an Association of Clinical Documentation Improvement Specialists (ACDIS) Advisory Board member and independent consultant based in Madison, WI.

This combined review could mean new vulnerabilities for hospital and physician reimbursement, but it also represents a new opportunity for CDI specialists: outpatient record review.

“We [as CDI specialists] are trying to get buy-in, support, from physicians,” Krauss says. “But we don’t explain how documentation affects their business. Outpatient documentation review is a good segue for helping physicians understand the importance of documentation in the medical record.”

Expanding ED efforts
At Advocate BroMenn Medical Center in Normal, IL, coders identified a number of concerns with outpatient, emergency department (ED), and nursing documentation, says Avery E. Trickey, RHIA, manager of the HIM department there. Trickey spoke to ACDIS members about ED/outpatient reviews during the association’s Quarterly Conference Call on November 17, 2011. Trickey also answered a CDI Week special Q&A on the topic in September 2011.

“Our CDI program was plugging along, and as time went by, we decided we should look at these different areas,” says Trickey.

Advocate BroMenn’s CDI program employs four fulltime equivalent (FTE) staff members, all of whom are RHIAs. The team reviews neurology, intermediate care, critical, surgical, rehabilitation, and cardiology, as well as ED records.

Because coders at Advocate BroMenn assign charges, they were aware of how much the facility might have been able to garner had the documentation been complete.

Armed with this knowledge, the team audited 100% of records for two weeks and established a figure for what would have been recouped in charges had the appropriate documentation been included. The team then extrapolated that figure out over a year, noting an estimated $350,000 in potentially lost reimbursement.

To get ED reviews started, Trickey pored over the ACDIS website, reviewed conference PowerPoint® presentations regarding outpatient/ED CDI efforts, and started conversations with the ED leadership. Each CDI specialist spent time in the ED to study the patients, staff, and work flow. They established relationships with the nurses and physicians and determined how documentation reviews might be conducted.

Now two CDI specialists spend dedicated two-hour shifts in the ED during the week, in addition to tending inpatient units for reviews. Staff members switch off every other week, so if someone goes on vacation or is absent everyone understands the process and can fill in if need be, Trickey says.

“We’re [in the ED] from [roughly] 5–8 a.m. to look at any charts from the overnight shift before the nurses leave, and then again from 1–3 p.m. before the next shift comes in,” Trickey says. “That way we can ask for clarification while they’re still there.”

Adding outpatient opportunities
Although Trickey hasn’t rolled out CDI efforts as they relate to medical necessity, Advocate BroMenn’s patient accounts department approached the CDI team looking for help in that regard, she says.

Outpatient care includes both high-volume and high-cost procedures, says Krauss. As a result, CDI programs may wish to establish medical necessity reviews as well. “Physicians’ orders account for approximately 90% of healthcare spending through their pen, through ordering of diagnostic tests and other patient services such as rehab, radiology tests to name just a couple,” he says.

Medicare releases national coverage determinations (NCD) while its contractors issue local coverage determinations (LCD), which explain under what circumstance a certain treatment or procedure will be reimbursed. The conditions can be complex and require more than simply capturing the diagnosis on the claim.

Getting started: First steps
To start reviews on the outpatient side, conduct a retrospective review of your facility’s top 20 denials for outpatient procedures, Krauss says. Then determine what the NCD and LCD documentation requirements are for those procedures.

Next, pull a selection of records for each of the top denials and compare their documentation against the requirements, taking note of areas where the medical record falls short. Also note whether deficits in documentation stem from one particular physician or whether the problem exists across a particular service line, Krauss says.

Armed with your audit research, approach key staff members such as a department chair, medical staff director, or health information management (HIM) director to share the information you’ve gathered.

Illustrate the potential losses and have a plan ready to help resolve the concern, says Krauss. Such a plan might include creating a new physician order form or documentation tip sheet to make it easier for physicians to document their orders in the most appropriate and compliant manner. It might also include additional educational efforts from the CDI team or one-on-one interventions with particular physicians.

If you receive approval to conduct additional education sessions, do so armed with specific data, says Krauss. Have examples of lacking documentation and appropriate documentation using actual copies of physician medical record documentation.

Bring examples of coverage determinations and key provisions of the LCD/NCD including Indication and Limitations of Coverage as well as specific medical record documentation requirements. Show physicians where the rules are located.

llustrate how documentation improvement isn’t just a program to boost facility reimbursement—demonstrate how it helps physicians’ business as well.

Focusing efforts
An analysis of denials at one hospital revealed a high percentage of denials for blepharoplasty procedures for ptosis of eyelids. Often these are considered cosmetic in nature.

Cosmetic procedures for the most part are not considered a Medicare-covered benefit and, as such, are statutorily excluded. According to National Government Services (NGS), a MAC:

Based upon specific definitions ... surgery of the upper eyelids is reconstructive when it provides functional vision and/or visual field benefits or improves the functioning of a malformed or degenerated body member, but cosmetic when done to enhance aesthetic appearance. ... Any procedure(s) involving blepharoplasty and billed to this contractor must be supported by documented patient complaints which justify functional surgery. This documentation must address the signs and symptoms commonly found in association with ptosis, pseudoptosis, blepharochalasis, and/or dermatochalasis ...

Krauss ran a report of the denials encountered for all blepharoplasty procedures performed at the outpatient surgery center for the past year, identified trends by physicians, and selected a representative sample of these denials by physicians.

He then reviewed the dictated operative note identifying clinical documentation deficiencies as defined by the NGS. Krauss met with the outpatient surgery nurse director, reviewed the documentation as compared to the requirements, and asked for her advice about how to communicate to the physicians.

Krauss then made appointments to meet the four physicians who had a disproportionate share of denials for blepharoplasty and showed them their dictated reports against the NGS guidelines and the Wisconsin Physicians Service Insurance Corporation, Part B Medicare carrier’s LCD, to illustrate how similar both guidelines are.

“The physicians are busy trying to stay in business,” says Krauss. “They can’t keep up with all the documentation requirements. Now, along comes the CDI specialist who offers to help them stay on top of the different documentation requirements. Don’t you think that will help make a difference in the physician’s involvement with the CDI program?”

Editor’s note: This article originally appeared in the January issue of the CDI Journal. Contact Krauss via e-mail at

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