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Recent ICD-10 Updates Reflect Push Toward Improving Outpatient and Ambulatory Documentation

April 1, 2021
April 1, 2021

This post excerpts our article, “ICD-10 Updates for 2018 Drill into the Need for Robust Collecting of Hierarchical Data,” based on an interview with Susan Gurzynski-Wells, MS, RHIA, Senior Product Manager, Revenue Cycle, for HealthStream.

“As more attention is paid to HCCs, physicians are going to be tasked more with documenting in the ambulatory setting,” Gurzynski-Wells points out. “Physicians are really important in that they are the ones who have to capture those HCCs. Now, as more of healthcare is moving into an outpatient or ambulatory setting, it’s important for ambulatory documentation to continue to improve.”

The coding changes highlight, as they were perhaps meant to, the disparity in data capture in outpatient and ambulatory Clinical Documentation Improvement, or CDI, efforts and their inpatient counterparts. Put simply, outpatient CDI programs are behind the curve. Even as more health systems move into the community via ambulatory surgery centers, outpatient clinics, freestanding emergency rooms and other non-hospital service centers, their ability to properly document care is only just now following those practitioners out of the acute care setting.

The Growth of Outpatient CDI

According to a survey performed by the Association of Clinical Documentation Improvement Specialists, “Only 10 percent of hospitals currently possess an outpatient CDI program. However, survey data also shows outpatient CDI is becoming more common; more than 20 percent of respondents indicated that they plan to cover outpatient and/or physician services in the next six to 12 months. Clearly, this is an area of growth and opportunity.” (ACDIS, 2016)

What this means is that as a patient’s status (inpatient or outpatient) is assessed, and treatment begun, coding will need to be followed carefully wherever that happens in order to ensure coverage determinations and reduce the possibility of denial. It also means that diagnoses around HCCs, which normally fall into the physician-practice arena, now can fall into an outpatient CDI program’s orbit more frequently because those patients aren’t being seen only in doctor’s offices.

Focus on HCCs

“The HCC-related coding changes are being done to make sure that dollars being paid to physicians align with making sure that the sicker patients are being treated,” Gurzynski-Wells says. “That’s really important, but there can be gaps. Healthcare systems and physicians have to make sure all their patients are documented, not just the ones they see frequently. This is a major point for those patients who will be coded with an HCC. If you have someone who only goes in when they are sick, who takes care of him- or herself and has all their vaccinations, watches their blood pressure and so forth, that person is not in the office regularly. They are a bad patient as far as documentation is concerned, because they may have a condition that’s not being seen; if they miss an appointment, they may not have an HCC captured. Their chronic condition that may represent a health risk won’t be documented that year, and therefore, not captured as an HCC. That can affect reimbursement.”

A Wellness-based Healthcare Model

Healthcare’s shift towards a wellness-based model comes into play here. Warding off chronic conditions, or catching them early, is the mantra of a system where both care and reimbursement models have moved toward preventative care vs. fee for service. That means the physician’s office may need to reach out to that patient to schedule a wellness visit, and then code for chronic conditions that may be emerging, in order for a CDI program to work.

“With the diagnosis-related group, or DRG, system there was underreporting,” she says. “If a physician omits reporting and coding an HCC for a patient because that patient hasn’t been seen, then the record is incomplete. For example, a patient who has had an amputation has a condition that’s not going away and that also creates a risk for the patient’s health. They may require more frequent care. That is why CMS is now doing risk-adjustment audits, and with ICD-10 that is becoming more important.”

References

ACDIS, “Outpatient Clinical Documentation Improvement (CDI): An Introduction.” May 2016. Accessed October 15, 2018. https://acdis.org/system/files/resources/outpatient-cdi-intro.pdf.

Download the full article here.