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Creating an Outpatient CDI Program Integrated Into an Existing Inpatient CDI Program

Carrie Horn, MSHA, BBA, RN, CCDSDirector, Delivery System CDISpectrum HealthGrand Rapids, MI

Mary Brouwer, MSHA, BSN, RN, CCDSManager, Concurrent Clinical Assurance Spectrum HealthGrand Rapids, MI

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Develop effective processes for a collaborative and cross‐disciplinary review approach

– Explain scope and objectives of outpatient CDI

– Develop outpatient CDI strategies based on physician documentation

– Describe best practices

– Describe metrics used to track national benchmarks

2018 Copyright, HCPro, a brand of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Polling Question #1

Does your facility have an outpatient CDI program?

– Yes

– No, and we’re not considering it

– No, but we’re considering it


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Polling Question #2

What qualifications are required for your facility’s CDI staff?

– RN

– Coding certification

– LPN

– We have a combination of coding associates and RNs on the CDI team

– Other

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Spectrum Health Delivery System CDI

The journey to outpatient CDI


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Concurrent Clinical Assurance Program

• Inpatient CDI team – 21 registered nurses

• 6 years clinical experience

• Bachelor’s prepared

• CCDS

• Certified in nursing specialty

• ICD‐10 diagnosis and procedure AHIMA certified

• PowerNote trained/Epic super users

• Coverage for 11 inpatient campus locations – Children’s hospital

– Level I trauma center

– Acute care

– Critical care

– Inpatient rehabilitation

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Professional CDI: Phase I

• Program name: Professional coding education department• Scope of work

− Professional coding associate education

− Coding education for all providers

• Professional coding education staff– 18 Certified Professional Coders

– RHIT

– ICD‐10 diagnosis AHIMA certified

– Certified in risk adjustment coding

– Certified rural health coding and billing

– Epic super users

• Coverage for 180 ambulatory practices• 3,600 system providers• 1,500 Spectrum Health medical group providers


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Goal: Comprehensive CDI Model

Inpatient CDI Nursing

Professional Coding Education

Service Line FocusedOne Provider

Message by OneTeam

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Provider Onboarding: Phase I

First week/30 days of employment/transition

• Service line–specific inpatient documentation opportunities shared

• Rounding established and preference for query delivery

• Overview of professional coding guidelines

• Concurrent chart review

Two‐, four‐, and six‐month follow‐up

• Provider notes from the previous week reviewed for documentation opportunities

• Two‐hour rounding with professional educator is held to review E/M opportunities

• CDI nurse reviews inpatient documentation and query trends


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Provider and Service Line Audits: Phase I

CDI nurse• Top 10 diagnoses

• Top 10 queries placed in the last year

• Average query response time per provider

• Average query impact

• Education on unspecified codes

• Discussion of variances for length of stay

• Average severity of illness and risk of mortality scores

• DRG denial trends and documentation education

Professional coding education • 6‐month review of bell curve by

provider and specialty compared to peers and national standards

• Provider/coder CPT code selection changes

• Documentation opportunities for E/M levels (20 chart review)

• Top 10 HCCs and diagnosis specificity

• Top 10 unspecified diagnoses with specificity opportunity

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Rounding: Phase I

CDI nurse

• Participates in daily multidisciplinary rounds with physicians, APPs, and residents

• “At the elbow” support for documentation accuracy and revenue optimization

• Tracks quality measures, severity of illness, risk of mortality, and length of stay variances

Professional coding education

• Provider rounding for inpatient cardiology, neurology, and hospitalists

• Delivery system rounding limited to onboarding and targeted opportunities as brought forward by providers, coders, and others


Provider Coder

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Sample Provider Metrics

Top 10 DRGs

• Knee Joint Replacement

• Hip Joint Replacement

• Shoulder, Upper Arm, Forearm Procedure

• Knee & Lower Leg Procedure Excision Foot

• Hip/Femur Procedure Excision Joint Replacement – Trauma

• Hip/Femur Procedure Excision Joint Replacement – Non‐Trauma

• Other Musculoskeletal Procedure

• Foot & Toe Procedures

• Tendon/Muscle/Soft Tissue Procedure

• Postop/Trauma/Developed Infection with Procedure


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Inpatient Provider Score Card

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Sample Provider Metrics

Query Types Top 10 Unspecified Diagnosis


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Lessons Learned: Phase I

Opportunities

• Workflow

– Access to shared files

– Optimization of technology

– Timely provider feedback

– Bridging clinical/coding gap

• Meeting cadence

– Decreased inpatient CDI productivity

– Work‐life balance

Resolution • Developed team “M” drive

• Created standard work for education and delivery

• Partnered with inpatient CDI for provider rounding

• Implementation of single EHR

• MModal Fluency Direct/CDI Engage

• Transitioned inpatient CDI meeting support to high‐opportunity areas

• Transitioned coding education to coding quality team

• Separated coding associate and provider education sessions

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Lessons Learned: Phase I

Opportunities

• Consistent messaging

– Professional coding associates

– Providers

– Inpatient and professional CDI

• Actionable provider content

Resolution

• Increased leadership presence at provider presentations

• Aligned inpatient and professional CDI staff education role (senior CDI nurse)

• Creation of staff education in‐site page

• Revenue cycle service line meetings

• Updated provider score cards to include CDI analysis of documentation opportunities

• Online provider education modules

• Coordinated monthly provider education across service line and delivery system

• Interactive service line KPI tableau


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Professional CDI: Phase II

• Program renamed to Professional CDI• Scope of work

− Change from coding education focus to CDI education for providers

− Compliant professional query program implemented

− Focused HCC querying and rounding

• Professional CDI staff– 12 Certified Professional Coders

– RHIT

– 2 LPNs

– ICD‐10 diagnosis AHIMA certified

– CDIP certification

– CDEO certification

– CRC certification

– Certified rural health coding and billing

– Epic super users

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Provider Onboarding: Phase II

First week/30 days of employment/transition

• Service line–specific inpatient documentation opportunities shared with concurrent chart review

• Rounding established and preference for query delivery

• Overview of professional coding guidelines

• Mandatory provider SHLI modules – online

• Attendance at monthly provider huddle

Two‐, four‐, and six‐month follow‐up

• Provider notes from the previous week reviewed for documentation opportunities

• Two‐hour rounding with professional CDI is held to review E/M opportunities

• CDI nurse reviews inpatient documentation and query trends


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Rounding: Phase II

CDI nurse• Participates in daily

multidisciplinary rounds with physicians, APPs, and residents

• Provides “at the elbow” support for documentation accuracy and physician revenue optimization

• Tracks quality measures, severity of illness, risk of mortality, and length of stay variances

• Shares individual MModal CDI Engage alert activity

Professional CDI

• Provider, resident, and APP rounding for all inpatient and ambulatory sites as determined by quarterly MDI focus

• Daily rounding/querying at primary care sites for HCC specificity and diagnosis capture

• Shares individual MModal CDI Engage alert activity

• Additional provider rounding as requested/aligned with staffing resources

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Provider and Service Line Score Cards: Phase II

CDI nurse− CDI tableau created

• Top 10 diagnoses

• Top 10 queries placed in the last year

• Average query response time per provider

• Average query impact

• Education on unspecified codes

• Discussion of variances for length of stay

• Average severity of illness and risk of mortality scores

• DRG denial trends and documentation education

Professional CDI − Quarterly MDI huddle

• Review of bell curve data

• CPT code change activity

• Identify top 3 departments/specialty areas within the clinical service line for CDI rounding

• Focus on documenting work performed to capture full burden of illness and supporting medical necessity

─ Top 10 HCCs and diagnosis specificity

─ MModal CDI Engage reporting


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1194

2784

6236

3452

# Sessions Resolved + Satisfied # Documents # Ignored +Dismissed

CDI Engage Heart Failure Alerts

Heart Failure

Queries Not Associated with Alerts

(25)76%

Queries for Alert info (8)

24%

34 Heart Failure Queries


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Professional CDI Staff Orientation

• Outpatient CDI boot camp

• Body system education

• Query compliance training

• Rounding and shadowing with CDI nurse

• CDI certification readiness prep

• Monthly CEUs

• Presentation and communication workshops

• Chart review accuracy 90% for orientation release

• Quarterly quality audit accuracy of 95%

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How We Look Today

CDI quality and production


Professional CDI

Department

Inpatient CDI

Department

CDI Quality/Training Department

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Delivery System CDI Quality Department

− 6 service line–focused CDI quality/trainer RNs

• Service line quality audits

• Provider follow‐up for metric variances

• All‐provider continuing education

• Provider/APP/resident onboarding

• Service line CDI orientation and continued education

• Service line metric presentations

• CDI Engage alert library

• Ensure query templates updated as needed


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Enhanced Provider Education

Onboarding• Provider CDI toolkit

– Smart phrases

– Templates

– MModal CDI Engage alerts

– BPA alerts

– Query review

– Pocket guide

– CDI contact/rounding

• Occurs before care begins• Scheduled 1 day/week• Complete by week 4• Placed in CQA audit rotation

Score cards

• RAF score card

• Inpatient metrics/quality

• CQA accuracy

• MModal CDI Engage alert

• Individual to peer comparison

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Delivery System CDI Production

Professional CDI

• Review daily encounters in MModal HCC Collaborate

• Query providers for HCC and diagnosis specificity

• Round with providers when metric variances identified

CDI nurse

• Review daily inpatient admissions in MModal CDI Collaborate

• Concurrent provider queries

• Daily provider rounding


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CDI Second‐Level Optimization

• Analyzer tool for provider bell curve comparison

– Targeted risk and optimization reviews

• Quality audits driven by KPI metric variances

• Rule‐based work queues for quality audit reviews

• Staff KPI score cards aligned with provider/service line metrics (new score cards being developed)

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CDI Center of Excellence


CDI Center of Excellence

CDI

Coding

Informatics

Providers

HIM

Compliance

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Purpose and Cadence

• Meets monthly to review:– Service line metrics

– Governmental changes impacting documentation/coding

– Updates to policies

– Query review/updates

– MModal CDI Engage user activity

– Proposed program changes

– Provider toolkit optimization/updates

• Smart phrases

• Templates

– Technology updates/enhancements

– Clinical definition review/communication/education


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Service Line Reporting

• Distributed

• Monthly

• Quarterly

• Annually

• Content

• KPI metrics

• Opportunities/variances

• Education plan

• 90‐day follow‐up for ROI

• Upcoming reimbursement changes and impact

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Thank you. Questions?

Carrie Horn ‐ [email protected]

Mary Brouwer ‐ [email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.
