Outpatient clinical documentation improvement initiatives are gaining interest with providers as healthcare delivery models are transforming away from Fee-for-Service to Fee-for-Value and more third-party payers are incorporating some measure of risk adjustment through HCCs into the scheme of reimbursement. An effective outpatient CDI program embraces the vision, goals and objectives of improving the quality of clinical documentation that accurately reflects and reports the communication of actual care provided. Communication of patient care tells the true story of patient beginning in the physician’s office at every patient encounter, particularly considering the fact most of services performed in the hospital based setting are driven by documentation and physician orders generated in the physician’s office. Outpatient CDI is predicated upon enhancing and furthering clear, concise, consistent and complete documentation that answers and addresses the what, where, how, why, what for, what am I thinking, where, and what am I going to do when I get there conceptual thought process as an integral part of physician clinical judgment, medical decision making and analytical problem-solving skills. Simply put, outpatient CDI is not predicated upon strict diagnosis capture; instead it is predicated and founded on principles of best practice standards of clinical documentation supporting the communication of patient care extending from physician office encounter to physician order, service delivery, charging, coding, billing and the use of the diagnostic workup and treatment in the physician’s management of the patient.
Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAM
1.0 CEU – Clinical Data Management
September 19, 2017