Healthcare systems are realizing the importance of documentation quality, and how this data translates to reportable outcomes. As a result, we are seeing efforts to continue the ICD-10 educational momentum by expanding CDI efforts into the outpatient, ambulatory and physician practice settings. For an expanded version of this overview, reference our article Expanding CDI to Physician Practices, Journal of AHIMA, May 2016.

Complete and accurate documentation of medical necessity has a direct positive effect on cash flow and the overall successful operation of the business, not the least of which is avoiding audit. There are also new pressures from multiple regulatory and reimbursement reform efforts such as Alternative Payment Models (APMs), bundled payments and MACRA for providers to take a closer look at clinical documentation and identify areas where improvements are warranted. For all these reasons, it makes sense to strengthen CDI programs by expanding into ambulatory services and physician practices.

Examining CDI In Physician Practices

Going forward, CDI must be extremely targeted and thoughtful in physician practice settings. Responsible parties should be auditing documentation frequently to pinpoint specific areas for educational opportunities and training. It makes sense to shift thinking to a more proactive approach on the front end of documentation, where education and collaboration can expose vulnerabilities before they become problem for claims denials and audits. Five specific proactive steps are worth noting.

  1. Cloned notes and assessments – cloned notes often don’t match up with the chief complaint/history of present illness and the assessment, and raise red flags with payers.
  2. Medical necessity – the specific ICD-10 diagnosis codes a physician chooses can make or break a payer’s decision to deem services medically necessary.
  3. ICD-10 diagnosis specificity – the use of unspecified codes are becoming more problematic in practices. Previous quality reporting has not placed such a high premium on diagnosis specificity, but that is changing on October 1, 2016.
  4. E/M levels –over-coding or under-coding result in repeated denials by your payers.
  5. Bundling and modifier usage – identify when it’s appropriate to use a modifier when a particular procedure is inherent in a more extensive procedure performed at the same time.

Jump-Starting A CDI Program

There are three good ways to get started with strengthening a physician practice CDI program.

  • Hire a certified coding professional
  • Focus on collaboration
  • Seek assistance from hospital-based CDI specialists and HIM directors

Quality documentation enhances outcomes and ensures accurate revenue for physician practices. Now is the time to evaluate your CDI efforts and take steps to improve practice documentation. To read our full article on this topic, visit AHIMA at: