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Guest Post: Expanding the CDI focus to the outpatient arena, part 1

Editor’s note: Crystal Stalter, CPC, CCS-P, CDIP, is the CDI manager for M*Modal in Pittsburgh. She has more than 30 years of experience in healthcare focused on coding, compliance, and physician documentation concerns. Contact her at Opinions expressed are that of the author and do not represent HCPro or ACDIS. This article was previously published in Briefings on APCs and JustCoding. This is the first part of a two-part series. Please return to the blog next week to read the second part!

The focus for CDI specialists has historically been on the inpatient hospital stay. Reviews of the chart for conditions not fully documented and/or evidence of conditions not documented at all, has been standard practice.

However, with so many changes in the industry facing providers in their outpatient practices, the importance of CDI in places of service such as physician offices, ambulatory clinics, and urgent care clinics is even more vital.


Symposium update: Early bird pricing ends today

outpatient early bird

Early bird pricing ends today!

Today is the last day to get the Early Bird price for the first ever ACDIS Symposium: Outpatient CDI. Reserve your seat today, July 17, to take full advantage of the discount. The conference takes place from September 18-19 at the Hilton Oak Brook Resort and Conference Center in Oak Brook, Illinois.

ACDIS members receive a $100 discount on their conference tickets, bringing the price down to $805. [more]

Note from the Associate Editorial Director: Setting the outpatient CDI table

outpatient CDI table

Join us for the ACDIS Symposium: Outpatient CDI!

By Melissa Varnavas

The stew’s been simmering in the pot for a while now. All the separate ingredients are melding and the overwhelming aroma in the room is enticing. The stew is outpatient CDI. Its ingredients are multitudinous, varied.

  • Pinch of evaluation and management (E/M) coding
  • Few cups of hierarchical condition category (HCC) groupings
  • Sampling of risk adjustment methodology
  • An awareness of current procedural terminology (CPT) codes
  • Knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting
  • Several specks of physician practice business savvy

And that’s not a comprehensive list of ingredients by any stretch of the imagination. Each cook in this CDI kitchen (just as in the inpatient world) follows its own recipe—drawing from its unique set of programmatic goals and overarching system mission and focus.

Yet, we have a basic recipe to follow thanks to those taste-testing the mixture over the past few years and sharing their samplings with rest of the CDI community. Now all we need to do is set the table and invite others to join us.

The ACDIS Symposium: Outpatient CDI invites you to the feast. Hope to see you there.

Editor’s note: Varnavas is the Associate Editorial Director for ACDIS and has worked with its parent company for nearly 12 years. Contact her at

CDI Week 2017 theme chosen

CDI week poll results

The CDI Week 2017 theme poll results

Over the past week, ACDIS asked its members to choose a theme for CDI Week 2017. Every year, facilities across the country celebrate the efforts of their CDI programs for one week in September. This year’s event takes place September 18-22. To help facilitate the festivities, ACDIS chooses an annual theme.

The three options this year were:

  • Shoot for the stars
  • The wild west: New frontiers in CDI
  • Watering your CDI garden

After a week of racing neck-and-neck, the CDI Week 2017 theme has been chosen! This year’s theme will be—drumroll, please—“The Wild West: New Frontiers in CDI!”

While the ACDIS team will busily plan for CDI Week 2017 using the chosen theme, and we encourage you to do the same. Tell us your plans and let us know

how do you plan to use the theme and share your favorite CDI Week activity?

Email Linnea Archibald (

Measuring the effect of HCCs, part 3

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information about Hierarchical Condition Categories (HCCs), read this article from the CDI Journal by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS. To read the first part of this article, click here. To read the second part of the article, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

The effect of hierarchical condition categories (HCCs) may double as hospitals buy physician practices and form health systems made up of a spectrum of different types of providers. Physician reimbursement has become increasingly complex and some physicians find it easier to operate with the support of a larger organization. Organizations that were once solely hospital-based now have to grapple with the complexities of a different set of billing and reimbursement regulations, says James P. Fee, MD, CCS, CCDS, vice president of Enjoin, Collierville, Tennessee and a hospitalist at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana.

Fee’s seen a lot of interest in HCCs from large multi-practice groups affiliated with a larger organization and some smaller physician practices have also started to pay attention to HCCs, particularly if they work with a larger organization for EHR assistance to support meaningful use. “I think we’re at a tip of an iceberg in terms of interest in HCCs. I think providers have a lot more to learn about HCCs,” he says.

As provider organizations grow, they should create a program to collect and merge patient data for analysis just as payers do. This will give the provider insight into what reimbursement they can expect for certain patient populations and it can help pinpoint what departments need more help.


Book Excerpt: CDI’s role in inpatient-only procedure documentation


Debbie Mackaman, RHIA, CPCO, CCDS

By Debbie Mackaman, RHIA, CPCO, CCDS

Connect CDI, utilization review, and case management before the patient is discharged

When a procedure converts to an inpatient-only procedure during the surgery, the documentation process may get a little more complex. Analyze what happened during the procedure itself. If the inpatient-only procedure is performed on an emergency basis, it’s likely the admission order was not obtained prior to the procedure. The outcome for the patient will determine the next steps. If the patient expires, no further action is required by the registration or operating room staff. The coding and billing teams take over resolution of the case.

If the patient does not expire, the surgeon should confirm the type of surgery originally scheduled and the reason for the needed change to the inpatient-only procedure. He or she should do so before the patient leaves the postoperative area. The care team needs to make a determination regarding the admission of that patient. Under current CMS guidance, the three-day payment window may apply in this scenario. The case should be held for billing purposes until a thorough post-discharge review can be completed.


Q&A: Best practices in time documentation


Got CDI questions? Ask ACDIS!

Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.

A: Time is always one of those really fun things, especially with E/M codes, because CPT puts a vague description of time amount requirements out there. So often, I end up having to query the physicians for time spend performing a procedure. I always like to have them explain the time. For example, he or she could say, “I spent 20 minutes of our 30-minute visit explaining how to properly use a new asthma inhaler.” That explains, how the physician met with the patient for 30 minutes and out of that time, used 20 minutes to explain how to use the new inhaler rather than just saying, “I spent 20 minutes discussing counseling or coordination of care.”

The other area that I always like to mention is sometimes time is best documented as “time in, time out.” Physicians are going to add that time up all day, especially if it’s a critical care patient. Physicians may want to get in the habit of documenting, “I walked in the patient’s room at 9:05 a.m. and we did our full thorough E/M exam and medical decision-making. I walked out of the patient’s room at 9:45 a.m.” So now coders have 40 minutes that a physician spent with the patient. And then a physician may go back into the room three hours later and document, “Patient was not responding well to those previous interventions. I now am back in the room at 11:18 a.m. and I spent from 11:18 a.m. until 1 p.m. with the patient and we’re still working on these interventions.” Then coders can add up all those time increments.

So to me, the best way I’ve found for providers to calculate E/M time is to document how many minutes of the total visit time that he or she spent counseling, doing coordination care, or what the provider talked to the patient about. But when I’m auditing inpatient records, I like to see the time in and time out and a bulk amount of time at the end of the day that I can add up to bill for that full-time increment and to know it’s all accounted for.

Editor’s Note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, answered this question during the HCPro webinar “Coding and Reporting Medical Necessity: Essentials for Coders and Other Healthcare Professionals.” This Q&A originally appeared in JustCoding

Measuring the effect of HCCs, part 2

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information about Hierarchical Condition Categories (HCCs), read this article from the CDI Journal by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS. To read the third part of this article, come back to the blog next week. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Separate rumors from facts in relation to risk-adjustment

Organizations may mistakenly believe that hierarchical condition categories (HCCs) are currently being applied to all reimbursement models and CDI program staff may not understand the nuances of how risk adjustments get calculated for certain claims-based outcomes such as mortality or readmissions, says James P. Fee, MD, CCS, CCDS, vice president of Enjoin, Collierville, Tennessee.

Organizations need to begin understanding HCCs and what their risk-adjustment factor (RAF) is, but these codes do not currently affect all reimbursement models across the board. For example, HCCs primarily affect the cost category of MIPS. The relative category weighting for cost is 0% for 2017 but will be 30% for 2019 and will not begin to affect payment until 2020. Evaluate what metrics and reimbursement are affected by HCCs and target resources.

“All of these risk-adjustment methodologies and HCCs in particular are being used in compensation in ACOs and in the value-based purchasing models that we’re looking at for future reimbursement,” says Monica Pappas, RHIA, president of MPA Consulting, Inc., in Long Beach, California. “So we really have to learn more about the system and be more informed about the impact of some of these codes that we typically don’t pay attention to.”

Organizations already specify if codes are complications or comorbidities or major complications or comorbidities and make calculations based on Medicare Severity-Diagnosis Related Groups. The same general principles can be applied to HCCs, Pappas says. Although the sheer number of codes can seem overwhelming, hospitals can work with vendors to create systems to track and flag the codes, and many HCCs fall in the same category, she says.

Coders and CDI professionals can use that as a shortcut to help them remember common targets. As demand rises, vendors will likely develop more sophisticated tools to assist in identifying these codes, flagging documentation for physicians and CDI specialists, and analyzing data.

“I don’t think any human being is capable of knowing all this,” she says. “The amount of information is massive and if we don’t look to some technology solutions, we’ll never win.”


Measuring the effect of HCCs, part 1

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information about Hierarchical Condition Categories (HCCs), read this article from the CDI Journal by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS. To read the second part of this article, come back to the blog next week. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Evolving reimbursement methodologies and regulations can make it difficult for an organization to prepare for the future. Some may choose to stick to current processes but savvy organizations should be looking ahead. Risk-adjusted and value-based models are the future of reimbursement, for both commercial and government payers. Organizations must keep the doors open today while building a solid foundation for the years to come.

These changes and challenges require organizations to pay attention to a sometimes neglected coding topic: hierarchical condition categories (HCC). HCCs are the basis for risk adjustments for reimbursement models like Medicare Advantage, accountable care organizations (ACO), and other value-based purchasing measures such as Medicare Spending Per Beneficiary. Poor understanding and application of HCCs mean that a hospital’s patients may be much sicker in reality than they appear to be on paper. And that will hit reimbursement hard.

Because HCCs generally apply to only certain patient populations, identifying those patients from the start can help focus efforts. Work with information systems, EHR vendor, and front desk staff to ensure an understanding of the financial classes or insurance plans for Medicare Advantage patients. It can sometimes be difficult for a provider organization to pin down the impact of HCCs because it’s less straightforward than other models, says Monica Pappas, RHIA, president of MPA Consulting, Inc., in Long Beach, California. Medicare Advantage payments are calculated once a year and the rate is set by CMS, communicated to the payer, and then to the provider via contract.  “The complexity comes from the fact that all of the hospital’s inpatient and outpatient data, plus the professional data is merged at the health plan and then scrubbed and ultimately submitted to CMS,” says Pappas

CMS analyses the data. The agency then determines what the yearly payment will be for a patient based on that patient’s particular set of aggregated data.

Some organizations may not even be aware of how HCCs affect Medicare Advantage payments, says James P. Fee, MD, CCS, CCDS, vice president of Enjoin, Collierville, Tennessee and a hospitalist at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana. If an organization did not have a risk-bearing contract with its Medicare Advantage payer, it didn’t need to know about HCCs. The onus would be on the payer to drive risk scores to determine capitated rates and prospective payments with CMS for the fiscal year. But new reimbursement models are changing the game for providers. Health Care Options (HCO), ACOs, and the Merit-based Incentive Payment System (MIPS) all use HCC risk adjustments. Providers taking part in these programs are suddenly getting interested in HCCs, Fee says, but they may have more to learn than they realize.

“HCCs are going to be the next greatest impact for CDI, whether that be determining a capitated rate and prospective payment models such as Medicare Advantage, to some of the next gen ACOs and ACOs in general,” Fee says. “HCCs run the gamut if you look at the industry in general. It’s a changing world for organizations because if you haven’t been in this space then you’re not quite aware.”


Conference Q&A: DeVault illuminates the shift to outpatient CDI


Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA

Editor’s Note: Over the coming weeks, we’ll introduce a few of this year’s speakers who are heading to the podium for the ACDIS 10th Annual Conference which takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we talked with Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, manager, HIM Consulting Services for United Audit Systems, Inc., who presents “Clinical Documentation Improvement – From Inpatient to Outpatient: Defining the different documentation, coding, and reimbursement requirements.” She has more than 25 years of experience in HIM serving as the senior director of HIM practice excellence, coding and reimbursement for AHIMA from 2008 to 2014.

Q: What made your company want to expand into the outpatient setting?

A: We noticed that it was the next natural progression in the CDI world. With hierarchical condition categories (HCCs), Medicare Access and CHIP Reauthorization Act (MACRA), risk adjustment, etc., it’s really a prime time for CDI. Where to start is the hard part. With inpatient documentation reviews, CDI professionals have a captive audience, so to speak. With outpatient, CDI programs need to look at all the different departments where physician documentation plays a role. On top of that, there’s the physician clinics. It’s very complex on how you move the well-oiled machine of inpatient CDI into the outpatient world – everything gets really muddied.

Q: What are three things attendees can expect from your session?

A: At the end of my session, attendees will be able to:

  1. Start to delineate what outpatient CDI looks like in the post-acute care setting. It’s not as simple as duplicating your inpatient CDI program
  2. How inpatient and outpatient CDI roles differ; and
  3. Some tools to build the framework for outpatient CDI. Your CDI framework could look very different and you need to do active discovery. CDI looks different in every setting based on where their needs are.

Q: Who should attend your presentation and why?

A: CDI specialists and anyone who’s involved with coding and CDI – CDI managers, finance side, directors, HIM directors, coding managers, coders, and even physicians! Essentially, it would be good for everybody. Anybody trying to figure out what outpatient CDI looks like should definitely attend. It’s like the transition to ICD-10 in that we need to think about how we eat the elephant one bite at a time. Outpatient CDI is a whole new elephant.

Q: What’s one tool no CDI professional should be without?

A: A CDI specialist should always have their communication skills. A CDI specialist is in a unique position because they live in the middle. They need to have a relationship with providers and then they also need that communication with coders.

Q: What are you most looking forward to about this year’s conference?

A: Networking! Last year, was the first year I was there as a vendor. It’s so fun to meet our clients. It’s great to put a face to a name!

Q: Fun question: what’s your favorite movie?

A: I’m kind of a sap, so I love PS. I Love you. I also really love Brian’s Song.