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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Available June 2017

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

Anny P. Yuen, RHIA, CCS, CCDS, CDIP
Page Knauss, BSN, RN, 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.


Page Count: 150
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