First Steps in Outpatient CDI: Tips and Tools for Building a Program

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First Steps in Outpatient CDI: Tips and Tools for Building a Program

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First Steps in Outpatient CDI: Tips and Tools for Building a Program

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First Steps in Outpatient CDI: Tips and Tools for Building a Program

Authors:
Anny P. Yuen, RHIA, CCS, CCDS, CDIP
Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO

Contributing Editor: Linda M. Huckin, RN, BSN, LNC, ACM, CPC, CDEO

Find best practices and helpful advice for getting started in outpatient CDI with First Steps in Outpatient CDI: Tips and Tools for Building a Program. This first-of-its-kind book provides an overview of what outpatient CDI entails, covers industry guidance and standards for outpatient documentation, reviews the duties of outpatient CDI specialists, and examines how to obtain backing from leadership.

Accurate documentation is important not just for code assignment, but also for a variety of quality and reimbursement concerns. In the past decade, outpatient visits increased by 44% while hospital visits decreased by nearly 20%, according to the Medicare Payment Advisory Commission. However, just because physicians are outside the hospital walls doesn’t mean they’re free from documentation challenges. For these reasons, CDI programs are offering their assistance to physician practices, ambulatory surgical centers, and even emergency rooms. This book will explore those opportunities and take a look at how others are expanding their record review efforts in the outpatient world.

This book will help you:

  • Target the outpatient settings that offer the greatest CDI opportunities
  • Understand the quality and payment initiatives affecting outpatient services
  • Understand the coding differences between inpatient and outpatient settings
  • Identify data targets
  • Incorporate physician needs to ensure support for program expansion
  • Assess needs by program type


About the Authors:

Anny P. Yuen, RHIA, CCS, CCDS, CDIP, is a health information management (HIM) and clinical documentation improvement (CDI) professional with extensive experience in healthcare and revenue cycle consulting. Yuen serves as the VP of revenue cycle for R3 Health Solutions. She is an active member of the American Health Information Management Association (AHIMA), the Association of Clinical Documentation Improvement Specialists, and the Philadelphia/Southern New Jersey local ACDIS chapter. Yuen coauthored The Complete Guide to CDI Management. She holds a Bachelor of Science degree in HIM from Temple University, where she minored in business, and is an AHIMA-approved ICD-10-CM/PCS trainer.

Page Knauss, BSN, RN, LNC, ACM, CPC, CDEO, works as an outpatient CDI specialist. As part of the CDI team, she performs medical record reviews for PQRS and educates providers on everything outpatient including RAF, HCCs, MIPS, MACRA, and ACOs.

Contributing Editor: Linda M. Huckin, RN, BSN, LNC, ACM, CPC, CDEO


Published: June 2017

Page Count: 13.4
Dimensions: 8 1/2 X 11 Perfect Bound 
ISBN: 978-1-68308-109-8

Table of Contents

  • Forward
  • Introduction
  • Chapter 1: Shift to Quality Spurs Outpatient Documentation Opportunities
    • Affordable Care Act
    • Value-based purchasing
    • Hospital and physician quality reporting programs
    • Risk-adjustment payment methods
    • Hierarchical Condition Categories
    • Merit-Based Incentive Payment System
    • Medicare Access and CHIP Reauthorization Act of 2015
    • Overview of outpatient setting focus areas
  • Chapter 2: Coding and Documentation in Outpatient Settings
    • Increases in outpatient services
    • International Classification of Diseases (ICD-10-CM/PCS) code assignment
    • Official Guidelines for Coding and Reporting
    • Outpatient prospective payment system (OPPS)
    • Ambulatory Payment Classification (APC)
    • Healthcare Common Procedure Coding System (HCPCS)
    • Current Procedural Terminology
    • Evaluation and management codes
    • Payment status indicators
  • Chapter 3: Engaging Providers
    • Competing priorities
    • Addressing physician differences
    • Physician involvement in program design
    • Data sharing and metric analysis
  • Chapter 4: Conducting Compliant Clinical Documentation Improvement
    • Medicare Conditions of Participation
    • Medicare Benefit Policy Manual
    • Medicare Claims Processing Manual
    • Medical necessity
    • National and local coverage determinations
    • Outpatient documentation guidelines
  • Chapter 5: Measuring CDI Impact on Outpatient Records
    • Return on investment
    • Analyzing data
    • Implementation costs
    • Productivity measures
    • Benchmarking data
  • Chapter 6: CDI in the Emergency Department
    • Documentation processes
    • Documentation to consider
    • Opportunities for CDI intervention
    • Staffing considerations
    • Reporting structure
    • Potential challenges 
  • Chapter 7: CDI in Ambulatory Surgery
    • Documentation processes
    • Documentation to consider
    • Opportunities for CDI intervention
    • Staffing considerations
    • Reporting structure
    • Potential challenges 
  • Chapter 8: CDI in Physician Practices 
    • Documentation processes
    • Documentation to consider
    • Opportunities for CDI intervention
    • Staffing considerations
    • Reporting structure
    • Potential challenges 
  • Appendix
  • Glossary
    • A day in the life of an outpatient CDI staff member
    • Examples of documentation improvement opportunities
    • Query options

Add Association of Clinical Documentation Integrity Specialists (ACDIS)

$20 discount on your one-year ACDIS Membership will be applied at check out.

ACDIS is a community of CDI professionals who share the latest tips, tools, and strategies to implement successful CDI programs and achieve professional growth.

ACDIS members receive: 

  • Advocacy and leadership from a peer-elected ACDIS Advisory Board, including peer-reviewed Position Papers and White Papers.
  • Weekly tips, news, and strategies in our e-newsletter, CDI Strategies
  • In-depth news and regulatory information, clinically-based articles, case studies on building successful CDI programs, and membership profiles in our bi-monthly electronic journal, the CDI Journal
  • An opportunity to network with peers and colleagues in the ACDIS Forum
  • Access to live and archived quarterly conference calls, hour-long networking discussions and an open Q&A with the ACDIS Advisory Board
  • Helpful tools accessed in our electronic Resource Library, including sample queries, policies, and archived conference presentations
  • Two free job postings a year, discounted additional posts, and the ability to post your resume on our Career Center
  • Opportunities to participate in an Official ACDIS Local Chapter in your area, under the leadership of the Chapter Advisory Board
  • Discounts to the annual ACDIS conference, CCDS certification, and CDI Boot Camps


To explore all that ACDIS has to offer, please
visit the ACDIS Web site.