The concept of outpatient CDI has been around since as early as 2003, but until very recently, few organizations had dedicated the time and energy to initiate an outpatient CDI program. The reasons for this are complex and range from the lack of qualified CDI professionals, to a suspicion by some of CDI initiatives generally, to time constraints that are unique to the outpatient setting. A recent poll, however, suggests that outpatient CDI is finally starting to gain traction.
A poll of over 400 respondents conducted in summer 2014 revealed that 35 percent had administered some form of outpatient CDI review. That is up from just 11 percent in 2008. Another 2 percent responded that they were planning to begin outpatient CDI reviews within a year. So while the number is still well below the majority, a consensus is growing around the efficacy of these programs.
Again, the reasons for the change are complicated. A stricter regulatory environment has created various mandates requiring providers to better reconcile hospital and physician billing. There has also been a growing acknowledgment among CDI professionals that inpatient-only initiatives are less than fully effective and often contribute to the characterization of CDI generally as merely a revenue grab. As we’ve come to better understand the complicated and interconnected ways the entire healthcare system inflates/cuts costs and improves/degrades outcomes, the need for outpatient CDI has begun to seem more urgent.
In order to demonstrate just how much revenue is lost by focusing only on inpatient care, advocates have audited representative samples of ER records. They have also audited the number of tests and labs that were canceled because the medical necessity could not be verified. This approach can’t deliver hard, incontrovertible data, but it can reveal a lot about the scope of the problem. In most cases, decision makers have been willing to invest the resources to pilot an outpatient CDI program with just estimates of its results.
The challenge of getting these pilot programs off the ground and running effectively has been that the focus of outpatient CDI falls on CPT codes rather than ICD-9-CM codes. The longer format of CPT codes has forced both CDI specialists and physicians to gain new areas of expertise, a process which is slow going by necessity.
Clearly, this is a concept that is still in its infancy. But with the regulatory environment becoming ever larger and more punitive, and the rollout of ICD-10 looming on the horizon, it’s a concept that will have to grow up fast. If you’re interested in exploring the feasibility of an outpatient CDI program, rely on the consulting and staffing solutions available from MedPartners HIM.