Outpatient CDI Pocket Guide: Focusing on HCCs - eBook

Richard D. Pinson, MD, FACP, CCS 
Cynthia L. Tang, RHIA, CCS 

New from the authors of the best-selling CDI Pocket Guide comes the first definitive reference guide for outpatient CDI. 

The Outpatient CDI Pocket Guide: Focusing on HCCs eBook makes capturing the most important information for your outpatients (and inpatients) a matter of understanding certain basic principles. Once you do, HCCs will be a breeze (relatively speaking). 

Authors Richard Pinson and Cynthia Tang clarify the chief considerations in outpatient reimbursement, documentation, and coding guidelines, and explain how HCCs affect both providers and insurers. With this guide, you’ll learn where to spend your energy—and where not to. 

You will benefit from this guide if you are a CDI or coding specialist, outpatient coder, risk adjustment specialist, nurse, or physician who seeks to: 

• Focus on areas of greatest impact as you expand your inpatient CDI program to the outpatient setting 
• Increase hospital and physician risk adjustments for value-based payments by improving capture of HCC diagnoses 
• Increase risk scores for a Medicare Advantage health plan 
• Ensure your practice or hospital’s outpatient coding meets clinical validation and documentation requirements 

About the Authors 

Richard D. Pinson, MD, FACP, CCS, is an educator, author, and CDI consultant with expertise in improving coding and clinical documentation, conveying diagnostic and evidence-based criteria, educating physicians, coding and CDI specialists, and transforming physician practice patterns and behaviors. He practiced emergency medicine and internal medicine for 25 years and is a Fellow of the American College of Physicians. He has authored the ACP Hospitalist Coding Corner for the past seven years. He is the co-author of the best-selling, authoritative CDI Pocket Guide. 

Cynthia L. Tang, RHIA, CCS, is an educator, author, and CDI consultant with expertise in health information management, coding, and clinical documentation improvement. She has more than 25 years of consulting experience in redesigning operations to improve coding and clinical documentation, promote hospital financial health, optimize reimbursement and compliance, and identify areas to improve care management and cost efficiency. She is the co-author of the best-selling, authoritative CDI Pocket Guide. 


Published: 09/18/2017 

Page count: 232 
Dimensions: 5 x 7 
ISBN: 978-0-9827664-7-7

Table of Contents

• Introduction: Hierarchical Condition Categories (HCCs)
• Who uses HCCs?
• Who will benefit from this guide?
• How to use this guide
• Glossary of Terms and Abbreviations
• Outpatient vs. Inpatient Payment Methodologies
• Hospital outpatient payment
• Physician payment 
• Formula for calculating the payment schedule
• Risk Adjustment and HCCs
• HCC payment methodology
• Hierarchies
• Disease interactions
• Diagnosis sources 
• HCC impact on health plans
• HCC risk adjustment effects on hospitals and physicians
• HCC impact on the provider
• CMS-HCCs vs. HHS-HCCs
• CMS Pay-for-Performance (P4P) Programs
• Hospital Value-Based Purchasing (VBP) Program
• Hospital Readmissions Reduction Program (HRRP)
• Hospital-Acquired Condition Reduction Program (HACRP)
• Physician Value Modifier (VM)
• Merit-based Incentive Payment System (MIPS)
• Outpatient CDI Programs 
• CDI in the physician office practice
• Opportunity review
• Data analysis
• Record review
• EHR optimization and process workflow
• Documentation and process improvement
• Prospective/concurrent process
• Retrospective review
• Education and training
• Monitoring and reporting
• HCC Capture in the Inpatient Setting
• GUIDELINES
• Outpatient coding guidelines
• Outpatient documentation requirements
• E/M guidelines
• Regulatory compliance
• KEY DIAGNOSES
• Aortic atherosclerosis/aneurysm
• Amputation status
• Cardiac dysrhythmia 
• Cardiomyopathy
• Chronic kidney disease
• Diabetic complications
• Heart failure
• HIV/AIDS
• Morbid obesity/BMI
• Paralysis (plegia and paresis) 
• Malnutrition
• Neoplasms
• Pulmonary hypertension and heart disease 
• Respiratory failure—chronic
• Skin ulcers
• Substance use, abuse, dependence
• HCCs
• List of common diagnoses with ICD-10 code, HCC, and weight
• CMS-HCC listing

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