Welcome to UASI’s Lunch and Learn: CDI Management Series We will begin shortly.

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UASI CDI/UR Service Line Stats

▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement

• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs

• CONSULTANTS average 8 years in CDI and/or UR, and 22 years in clinical nursing

• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing

UASI CDI/UR Services

Ten Key Steps to Successfully Implement

Outpatient CDI in a Physician PracticeStaci Josten, BSN, RN, CCDS

Director, CDI/UR Services, United Audit Systems, Inc.

Feb 2021

Desired Outcomes

At the end of this presentation, attendee will be able to:

• Understand the benefits of implementing outpatient CDI in a physician practice

• Explain the steps to initiate outpatient CDI in a physician practice

• Identify important keys to each step of implementing a successful Outpatient CDI program in physician practice

Polling Question

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Does your organization currently have an Outpatient CDI Program?

1. Yes, it’s going great

2. Yes, it’s in the pilot phase

3. Yes, but we need help

4. Not now, but planning in the near future

5. No, we don’t have any plans for an OP CDI Program

Benefits of Physician Practice Outpatient Clinical Documentation Improvement

• Accurate ICD 10 Code Assignment • Code assignment directly impacts hierarchical condition category (HCC)

assignment, which will impact the patient and population risk adjustment factor (RAF)

• Complete documentation of supported diagnoses (not just service levels)

• Appropriate reimbursement

• Accurate quality scores

• Reduction in denials

Assess Current State

• Identify areas of opportunity. Examples:

• Denial rates, RAF scores, Quality scores• Comprehensive Assessment to include:

• Investigate all documentation & coding processes• Baseline patient record review • Evaluate HCC data over 2 years• Case selection based on data-driven criteria

Assess Current

State

Define & Align

Set Program Goals

Determine ROI

Staffing Infrastructure

Define Workflow

Communicate, Educate

Performance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #1: Understand where issues exist

Patient Chart Review Tips

• Targeted approach to find opportunities

• Longitudinal risk-adjusted patient audit (not individual claims or encounters)

• Includes an evaluation of both documentation and final coding of HCC conditions on all claims in the current year for each patient

• Identify documentation and/or coding gaps

• Pre and post-review RAF score comparison

Compliant HCC Capture

HCC Change Opportunity Description Type

Diagnosis Documented – not coded Potential claim update; Diagnosis identified in health record but not reported on the claim

Coding

Diagnosis documented – more specified code supported

Potential claim update; Diagnosis identified in medical record, appears a more specific diagnosis is appropriate

Coding

Documentation supports dx – either not explicitly documented or not coded

Potential query opportunity; Information in the health record (clinical indicators) supports adding additional diagnosis if the physician agrees and documents more

specifically

CDI

Diagnosis coded – MEAT not found in health record

Potential query opportunity; Diagnosis identified in health record but no documented evidence of monitoring, evaluating, assessment, or treatment. Physician would need to further expand documentation for this diagnosis to be coded and reported on a claim

CDI

Outpatient CDI Audit Findings Example

ICD10CMCode Code Description

CMS-HCC Model Category

V24 HCC RAF ScoreFrequency of Occurrence in Potential HCC Changes

E6601 Morbid (severe) obesity due to excess calories 22 0.250 50

F320 Major depressive disorder, single episode, mild 59 0.309 28

F339 Major depressive disorder, recurrent, unspecified 59 0.309 24

E1165 Type 2 diabetes mellitus with hyperglycemia 18 0.302 20

N183 Chronic kidney disease, stage 3 (moderate) 138 0.069 18

J449 Chronic obstructive pulmonary disease, unspecified 111 0.335 8

E1122 Type 2 diabetes mellitus with diabetic chronic kidney disease 18 0.302 6

Potential HCC Changes Impacted 154

200 Patient Outpatient CDI Audit, 200 patients reviewed, 154 patients with opportunity77% of patients with HCC opportunity

Define Program Scope and Approach

• Determine scalable approach and reporting structure

• Define areas of focus for CDI efforts, for example:

• High volume, high revenue patients

• Members of specific health plans

• Primary care providers vs. certain specialties

• Start with a few area(s) for proof of concept and then refine and expand

Assess Current State

Define &

Align

Set Program Goals

Determine ROI

Staffing Infrastructure

Define Workflow

Communicate, Educate

Performance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #2: Determine initial area(s) of focus

Approaches• Selective Pre-visit review

• Specific doctors, clinics or specialties

• By visit type (e.g. annual visits, post-op appointments)

• Members of specific health plans (e.g. MA, ACOs)

• Identify and communicate documentation gaps, problem list redundancy/gaps

• During the visit (the day of the visit)• Address identified documentation gaps with provider

• Physician interactions/training (curb-side, at-the-elbow, skype and/or telephone calls)

• EHR diagnosis capture mechanisms

• Post-visit “back-end” processes• Close the loop – HCC work queues

• Code capture on the claims

• Provider reviews to share for educational purposes

Outline Goals and Ongoing Data Needs

• Determine data available and future data needs

• Align data collection formats to measure outcomes

• Set clear, measurable goals

Assess Current State

Define & Align

Set Program

GoalsDetermine ROI

Staffing Infrastructure

Define Workflow

Communicate, Educate

Performance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #3: Define the goal(s) and data needs based on assessment results and benchmarks

Data Analytics Examples and Tip

Code Comparison

Year Over Year Comparison

Use Disease Registries

Data Analysis Tip

• Narrow down patient populations to decrease volume of data to analyze

• Example: Select patients alive, enrolled in a risk adjusted plan, seen at least once by family practice or internal medicine

Determine Return on Investment

• Tactic to gain administrative support

• Demonstrate financial impact of RAF scores

• Lag time in RAF score reporting

• Extrapolation of chart review findings

• Specific to the patient population based on prevalence

Assess Current State

Define & Align

Set Program Goals

Determine ROIStaffing

InfrastructureDefine

WorkflowCommunicate,

EducatePerformance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #4: Determine way(s) to calculate financial impact

No Diagnoses RAF Score

Incomplete Documentation RAF Score

Complete Documentation RAF Score

76‐year‐old female,Community, Aged

76‐year‐old female,Community, Aged

76‐year‐old female,Community, Aged

Dual Full Benefits 0.593 Dual Full Benefits 0.593 Dual Full Benefits 0.593

CKD Stage 4 (HCC 137) 0.260 CKD Stage 4 (HCC 137) 0.260

Heart failure (HCC 85) 0.371 Heart failure (HCC 85) 0.371

Diabetes (HCC 19) 0.107 Diabetes w/renal complications (HCC 18) 0.340

Hemiplegia (HCC 103) 0.487

BKA status (HCC 189) 0.795

DM + HF + CKD 0.379 DM + HF + CKD 0.379

RAF 0.593 RAF 1.710 RAF 3.225

Estimated annualpayment

$5,550 Estimated annualpayment

$16,006 Estimated annualpayment

$30,203

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CMS-HCC Examples

Example of Financial Impact Extrapolation

Morbid Obesity (HCC 22) Population Example:

• 1500 of the patients in the ACO have BMI > 40

• 500 of these patients had a claim with a code for morbid obesity submitted (E66.01)

• 1000 patients did not have morbid obesity coded in 2020

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Potential Missed HCCs RAF Score for HCC 22 CMS annual base rate POTENTIAL Opportunity

1000 patients X 0.250 x $9366 = $2,341,500

Example of Potential Financial Impact

UASI Out patient CDI Audit Example

Average of Facility RAF 2020 Score

Average of UASI RAF Score

Average RAF Score Variance

1.0994 1.2374 0.1380

Patients with RAF Changes

Sum of Facility RAF 2020 Score

Sum of UASI RAF Score

Variance in Pre and Post Audit raw RAF

CMS-HCC model CY 2020, relative factor annual base rate for

all segments

Potential Annual Increase in Risk-

adjusted Reimbursement

872 921.99 1121.85 199.86 $ 9,366 $ 1,871,926**

**For this number to be realized, patients must be seen by provider, HCC documented/supported, and coded

Develop Staffing Infrastructure

• Program Leadership• HCCs & risk-adjusted payment knowledge

• CDI & coding knowledge

• Staff qualifications and reporting• Clinical expertise and coding expertise

• Establish staffing ratios• Determine number of clinics and providers

Assess Current State

Define & Align

Set Program

GoalsDetermine ROI

Staffing Infrastructure

Define Workflow

Communicate, Educate

Performance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #5: Form the initial team and team structure

Initial Staffing Recommendations

• Start with Pilot and work to expand to other providers and clinics

• Suggested Outpatient CDI Duties

• Streamline current pilot project work flow for pre-visit review process

• Review Risk adjusted payer patients during annual physicals

• Provide monthly education to assigned clinics and providers

• Assist in Post-Visit/Pre-Bill Work Queue and query providers as needed

• Initiate provider documentation audits

Define Initial Workflow & Processes

• Establish processes and procedures

• Insert CDI within the clinic workflow

• Resist the urge to mirror IP CDI process

• Leverage EHR functionality

Assess Current State

Define & Align

Set Program

Goals

Determine ROI

Staffing Infrastructure

Define Workflow

Communicate, Educate

Performance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #6: leverage current workflow, tools and staff

Outpatient CDI Process ExampleCDS Pre-Visit Review for

Targeted Visits

• Annual physical/ wellness visits

• Possible targeted diagnoses in the future

• Reviews conducted 1-2 weeks in advance

• Focus on Medicare Advantage and other risk-adjusted payers

• Goal of 25-30 new reviews per day

• Develop communication plan/query process for providers to know which chronic conditions should be addressed

Provider Engagement and Education

• Assign Outpatient CDS to Physician Practices

• Divide Practices/Providers per CDS (approximate 8 practices per current 3 CDSs)

• 1-2 clinic visits per week per CDS for site education and provider one on ones

• Complete documentation reviews on Providers

• Assign up to 50 provider chart audits per month per CDS to review results with Providers

• Complete feedback on reviews and opportunity for review for assigned providers

Post Visit and Pre Bill

• Create work queue in EHR for Pre Bill Review by CDSs and possible HCC Coder

• Examples of work queue holds:

• Depression unspecified

• CKD unspecified

• BMI > 40 without diagnosis of obesity or morbid obesity

• CDS will retrospectively query provider as needed

• CDS will maintain a monthly summary of bills held and corrected conditions, by practice and provider

Polling Question

For the first 6 steps we just discussed, what area do you feel is (or would be) the most challenging for your organization?

1. Assessing current state

2. Defining & aligning the Outpatient CDI Program

3. Setting program goals

4. Determine return on investment

5. Staffing infrastructure

6. Defining workflow

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Communicate & Educate

• Identify key stakeholders and all key players

• Communication plans

• Messaging to each audience

• Goals, timelines, progress, outcomes

• Education plans

• Be brief, use real examples

Assess Current State

Define & Align

Set Program

GoalsDetermine ROI

Staffing Infrastructure

Define Workflow

Communicate, Educate

Performance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #7: Get information to the right people at the right time

Provider Tip Sheet Example

Set Staff Performance Expectations

• Set clear staff performance expectations

• Everyone working toward the same goal

• Conduct time studies

• Develop realistic productivity goals

• Evaluate/adjust throughout the process

Assess Current State

Define & Align

Set Program

GoalsDetermine ROI

Staffing Infrastructure

Define Workflow

Communicate, Educate

Performance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #8: Communicate realistic expectations to staff

Outpatient CDI Staffing Expectations Example

Goal Range

Number of Assigned Providers

Number of Assigned Clinics

Number of Pre Visit Patient Reviews

Number of Post Visit Reviews

Number of Provider Audits

Goals will vary widely among organizations depending on the multiple variables

Monitor, Track , Measure

• Identify both process oriented and outcome oriented measures

• Record specific improvements• Actual and potential improvements

• Case level information

• Individual staff productivity

• Analyze trends, evaluate outcomes

Assess Current State

Define & Align

Set Program

Goals

Determine ROI

Staffing Infrastructure

Define Workflow

Communicate, Educate

Performance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #9: Identify KPI’s to monitor and analyze

Outpatient CDI Metric Tracking Example

Ongoing Program Evaluation

• Continue to evaluate the impact

• Reflect and refine program goals

• Continuously adjust approach to respond to evolving insights and changing priorities

• Periodic audits/QC to verify accuracy and consistency

Assess Current State

Define & Align

Set Program Goals

Determine ROIStaffing

InfrastructureDefine

WorkflowCommunicate,

EducatePerformance Expectations

Monitor Track

Ongoing Evaluation

Key to Step #10: Remain flexible, adapt, incorporate new ideas

Summary of Ten Key Steps To Successfully Implement Outpatient CDI in a Physician Practice

1. Understand where issues exist

2. Determine initial area(s) of focus

3. Define the goal(s) of the program and establish data needs of the program

4. Determine way(s) the program will show ROI

5. Form the team and team structure

6. Define initial workflows and processes

7. Outline comprehensive communication plan

8. Identify and communicate expectations to staff

9. Establish key performance indicators you will want to monitor and analyze

10. Evaluate process to identify additional opportunities and ways to gain efficiencies

Join us for the next

UASI CDI Management Series :“Outpatient CDI HCC Clinical Concepts”

March 24, 2021

email: info@uasisolutions.com for inviteuasisolutions.com | 31

Download the 2020 Passport to HCC’s on our UASI Solutions Website

http://marketing.uasisolutions.com/passport-to-hccs-fy19

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Questions ?

UASI CDI/UR Services

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UASI CDI/UR Services Stats

▪ 4 out of 5 UASI clients request ongoing or return services following an initial CDI engagement

• UASI works for top hospitals utilizing our experienced team of consultants to deliver value tailored to our client’s specific needs

• CONSULTANTS average 8 years in CDI and/or UR, and 22 years in clinical nursing

• MANAGERS average 11 years in CDI and/or UR and 24 years in clinical nursing

UASI at a Glance

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Headquarters:

Founded:

Clients:

Team:

Charts handled annually:

Solutions:

Experience

• Management: 22 years of HIM experience;

11 in CDI

• Coding staff: 8+ years

Quality

• 97% accuracy in coding

• 100% target for accuracy, certification and

meeting industry standards

Reliability

• 32+ years in business

• 40 clients in US News & World Report best

regional and honor roll hospitals

Culture

• People-centric, team-driven culture

• High employee satisfaction

• 20% new hires referred from current employee

• Industry-leading average employee tenure

Cincinnati, Ohio

1984

200+ hospitals/health systems nationwide

450+ employees, including AHIMA/AAPC-certified

coders, HIM and clinical documentation specialists

3.75 million coded; 200,000 audited

Coding Services, Coding Reviews, Clinical

Documentation Improvement, Revenue Integrity,

HIM Solutions, Strategic Consulting