with growth of outpatient care, providers need true ......revenue leakage, minimize compliance risk...

With Growth of Outpatient Care, Providers Need True Enterprise HIM

David Fletcher, MPH Senior Vice President, Innovation, Streamline Health, Inc.

(888) 997-8732 | www.StreamlineHealth.netQuality is the New Revenue™


Today’s hospitals are experiencing unprecedented

change, most notably the shift to value-based

payment models that reward high-quality, low-

cost care. It’s a new care paradigm that prioritizes

the effectiveness and cost of care over the volume of

services rendered. Does the care actually help patients,

and are providers rendering it as efficiently as possible?

In the quest to provide value-based care, providers are

shifting more inpatient services to lower-cost outpatient

settings to leverage more appropriate resources.

Organizations currently use a plethora of health

information technology (HIT) solutions to manage

inpatient reimbursement, but few have the technology

or processes in place to effectively optimize revenue

from their ballooning outpatient business.

Prior to now, the low per-case revenue, coupled with

incredibly high volume, meant providers simply didn’t

have the needed resources to focus on optimizing

outpatient documentation and coding. Now that

outpatient activity is skyrocketing, providers are

discovering that multiple factors, such as disparate

coding teams, inpatient-only CDI focus and outpatient-

specific requirements, stand in the way of optimizing

outpatient revenue integrity in an efficient, effective

manner.

Source: Medpac Report, March 2018

The power of integrated outpatient HIT

Integrated HIT combines two important processes in

the outpatient arena—clinical documentation integrity

(CDI) and coding— and helps simplify and improve some

key factors that drive revenue integrity.

First, does the documentation accurately reflect the

acuity of care delivered? Outpatient care documentation

and coding leverage several distinct criteria, including

risk-adjustment factors (RAFs) and more in-depth

consideration of Hierarchical Condition Categories

(HCCs). RAF scores are unique calculations that

ultimately affect many financial arrangements—Medicare

Advantage member payments, benchmarks and budgets

for commercial Accountable Care Organizations

(ACO) as well as ACOs participating in the Medicare

Shared Savings Program (MSSP), value-based incentive

payments, and more.

Chronic conditions classified into HCCs require more

resources and disease intervention in care delivery, and

the accurate and complete documentation of these

chronic conditions is critical to accurate reimbursement.

Diagnoses cannot be inferred from test results; they must

be documented in notes. Documentation must show that

the chronic condition was Monitored, Evaluated, Assessed

or Treated (MEAT). And this needs to be captured at

least once per year from in-person encounters. This type

of activity—and subsequent documentation and coding

requirements—calls for dedicated outpatient-specific HIT.

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Outpatient visits increased by 47% between

2006 and 2015

while inpatient discharges decreased

by nearly 20% during that same timeframe.



Second, does the subsequent coding accurately reflect

all of the available documentation? Without performing

a coding analysis prior to claim submission, it’s easy

for coders to overlook HCCs even when the supporting

documentation is specific. Inpatient diagnosis capture

that focuses on CC/MCC capture for DRG reimbursement

can miss significant HCC coding. This is problematic

because capturing HCCs in the outpatient setting may

be the only opportunity providers have to get credit

for treating these diagnoses—especially when patients

aren’t ever admitted to the hospital. When patients are

admitted, the Centers for Medicare & Medicaid Services

looks back at outpatient claims over a 12-month period

prior to any inpatient admission when calculating

population risk, thereby elevating the importance of

outpatient documentation. Another reason to focus on

HCC capture in outpatient settings? Doing so can help

providers identify—and prevent—care gaps that lead to

poor outcomes.

CDI and coding are co-dependent processes, and

therefore require highly integrated technology and

processes to be effectively administered. With integration

comes efficiency and compliance. And with compliance

comes the opportunity to focus more time and resources

on improving patient outcomes.

Emerging outpatient documentation challenges

Although many healthcare organizations have robust

inpatient CDI programs, they often lag behind in

effectively expanding these efforts into the outpatient setting.

There are several reasons why:

The high volume of outpatient services, coupled with much lower per-encounter revenue, has discouraged investment in this arena

It’s difficult to recruit and retain CDI specialists qualified to work in the outpatient setting

Lack of consistent coding and documentation protocols in system-owned physician practices requires significant operational changes before outpatient CDI efforts can truly take hold

Rapidly-evolving outpatient devices and technology require timely coder education

Return on investment may be slower (it could take at least a year to fully reap financial rewards)

Unlike inpatient CDI where patients are admitted, outpatient encounters often leave minimal time for a query or follow-up

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CDI and coding are co-dependent processes, and therefore require highly integrated technology and processes to be effectively administered.

“Every hospital has a different pain point: medical necessity denials, inadequate charge capture, E/M denials, and more. It’s hard to know where you should devote your resources to maximize the return on investment. However, with automation, you don’t need to choose. The result? Higher-quality outpatient documentation and coding across the board.” -Julius Blum, vice president of solutions management at Streamline Health



How integrated HIT enables five outpatient CDI best practices

Once launched, a successful outpatient CDI program

will address the following questions:

What is the current RAF score based on the documentation and codes provided?

How can we improve this RAF score to ensure revenue integrity? For example, can we obtain more specific documentation that translates to more specific codes? Did we accidentally omit one or more chronic conditions? Are there any clinical indicators that point to an HCC that’s present but not documented?

How does this RAF score compare with other similar patients in our health system? How does it compare with this same patient’s RAF score in the prior year?

Manually achieving the above requirements is virtually

impossible, and with outpatient care growing at

unprecedented rates, organizations that can’t optimize

compliant revenue from these services will suffer

increasingly negative consequences.

However, by leveraging leading edge technology,

organizations can achieve the following five best

practices for outpatient CDI:

1 Review 100% of outpatient cases prior to billing.

Use automated pre-bill coding analysis to prevent

revenue leakage, minimize compliance risk and

identify areas for education and process improvement

that would have otherwise gone unnoticed.

2 Move outpatient CDI efforts upstream in

the revenue cycle.

Whenever possible, don’t wait until the

patient has left the facility or clinic to determine

what information is missing. Instead, analyze

critical documentation (e.g., referrals, pre-operative

notes, patient histories, reason for visit) to identify

opportunities for documentation improvement so the

clinical care team can obtain clarification at the point of

care or even before the patient arrives.

3 Automate outpatient CDI and coding workflows.

Automation enables you to prioritize the

workload so outpatient CDI and coding

specialists can focus on cases with the greatest potential

impact. Use integrated HIT that automates or greatly

simplifies the following:

Work queue prioritization—Present cases that your organization has defined as high priority so CDI specialists can focus their efforts accordingly.

Physician Queries—Electronic queries make it easier to request and manage additional details.

Pre-bill analyses—Identify potential issues and opportunities and share with coding staff to optimize coding prior to bill submission.

4 Provide real-time feedback.

Show coders and outpatient CDI staff

how certain coding and documentation

changes could affect the RAF score so they can obtain

necessary clarification as quickly as possible—before

claims are submitted.

5 Let data—not assumptions—drive your

outpatient CDI program.

Examine HCC data from the previous year to

show trends by specialty and physician so you can dig

more deeply into questions such as, why do certain

physicians treat patients with lower RAF scores? Are

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these patients truly less complex? Do these physicians

forget to capture all HCCs, or are the HCCs typically

unspecified? Do certain practices over-code HCCs,

which skews the data? Use this information to initiate

compliance activities and guide strategic decisions

about your outpatient CDI program.

Why automated pre-bill coding analysis is critical

Even once coding is complete, there’s no guarantee

that it’s accurate or optimized. Unfortunately, most

feedback on coding accuracy comes either via payer

responses or post-billing audits, both of which offer

limited value. The result is a reactive strategy that will

never truly optimize your CDI and coding processes—

nor the resulting revenue they represent.

Automated pre-bill coding analysis of outpatient coding

allows organizations to analyze accuracy on all cases

before claims go out the door. Questionable content

is flagged, and coders are presented with information

regarding the potential for errors, what codes need to

change and why. High-impact cases are then routed to

the appropriate resource for review and correction—all

with minimal bill hold.

Just like with inpatient coding, the guidelines and

criteria supporting outpatient coding are constantly

evolving. In order to ensure your coding is optimized,

the rules behind its analysis should be continually

updated with any new information.

Ideally, such a system would be augmented by machine

learning that assesses all new information and updates

any related rules to reflect these new criteria accordingly.

This ensures that your coding is gauged based on the

most current information and the associated revenue is

optimized accordingly.

With integrated HIT, organizations can rest assured

they’re billing correctly for services rendered—and that

patients will receive high-quality care captured through

high-quality outpatient documentation. And as more of

your care moves to the outpatient setting, you can be

confident that you’ve adapted your HIM and Revenue

Cycle processes to support optimal compliant revenue.

“Machine learning propels outpatient CDI programs to the next level. The system can learn from thousands of encounters audited by our professional staff and apply more than 1,750 custom rules across all cases before the patient even comes in, allowing staff to pinpoint areas of documentation vulnerabilities. Organizations get the revenue they deserve, and patients experience the high-quality care they expect.” -David Fletcher, MPH, senior vice president of innovations at Streamline Health



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Do more with less

Prioritize e�orts

Drive accurate RAF scores

Capture all of the revenue to which you’re entitled

Enhance patient safety and satisfaction

Five strategic bene�ts of integrated Outpatient HIT

Use automation to augment your sta�’s ability to collect and validate information as early in the revenue cycle as possible— often before the patient even sets foot in your facility or clinic.

Minimize risk and optimize compliant revenue using a dynamic rules engine to scrutinize your outpatient documentation and coding.

Analyze historical information and code patterns to look for code omissions and opportunities for additional speci�city.

Reduce coding errors and omissions on the front end to capture compliant revenue across the board.

By reducing leakage and denials, you have more resources to improve care delivery and the patient experience.

About Streamline HealthStreamline Health is an industry leader in supporting revenue integrity for healthcare enterprises. Our integrated

solutions, technology-enabled services and analytics help providers manage their mid revenue cycle processes —

from charge capture to final bill drop — to optimize revenue integrity and reimbursements in a value-based world.

As innovators in HIT, Streamline Health proudly features Outpatient CDI and Outpatient eValuator™ to optimize

documentation and coding in support of maximum compliant revenue from outpatient services. To learn more,

visit www.streamlinehealth.net.

See next page for a table that summarizes the real-world impact of Outpatient HIT on documentation, coding and revenue integrity…



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Event Optimized HIM with Outpatient (OP) HIT

Patient makes appointment for Cataract Surgery (Pre Admit)

OP CDI team initiates case; performs Medical Necessity check (LCD/NCD)

Coding Coding team has access to optimized content to enable accurate, ecient coding.

Post Billing Provider is con�dent quality scores and CMI are accurate. Also assured that documentation/coding accurately capture HCCs and other data to protect future reimbursement for patient's care.

Ongoing Optimization System tracks denials to assist in custom rule development to prevent denials and proactively address issues behind bill holds. This further optimizes reimbursement and increases cash �ow.

Billing Provider submits 'clean' bill, preventing denial or unnecessary payment delays.

OP CDI collects any documentation prior to visit. Initiates Physician Queries as needed.

Day of Surgery OP CDI team begins working case; identi�es potential HCCs based on documentation

OP CDI notices potential Diabetes reference in documentation; queries Physician to clarify.

Upon con�rmation, updates HCCs to re�ect Diabetes

Real-time coding analysis enables sta� to assess E/M level

OP CDI team calculates RAF score to ensure it aligns with acuity of care for patient with Diabetes

Prior to billing, coding is automatically evaluated to con�rm accuracy and optimization

To find out how Streamline Health solutions can help optimize revenue integrity from your outpatient services, contact us at [email protected]

with growth of outpatient care, providers need true ......revenue leakage, minimize compliance risk...

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