• HQM

CDI expansion to the Outpatient Setting consider the following:

Three areas of opportunity:

–OPPS/ASC

–Hospital-based outpatient departments: ER, Observation, and Clinics.

–Community-based ambulatory care, surgery, and diagnostic procedure centers

Physician Fee Schedule

Hospital/Health System (HS) Employed Physician Group Practices

Private Independent Physician Group Practices

Risk Adjustment (RA) Payment Methodologies

–Hospital/HS that:

Own a Medicare Advantage (MA) health plan

Employ physicians with MA contracts that include RA score incentive

Participate in a ACO

Key Benefits in the Outpatient Setting

  • Accurate ICD Code Assignment: Specificity in diagnosis are equally important in the outpatient setting. Diagnoses should be documented to the highest level of specificity as supported by clinical substantiation. Impacts HCC assignment which in turns impacts the RAF score

  • Accurate CPT Code Assignment: CPT codes capture procedural specificity in the outpatient setting

  • Accurate Ambulatory Payment Classification: APC is the outpatient prospective payment system for hospitals. Accurate documentation to capture the appropriate APC assignment is equal to DRG assignment in the inpatient setting

  • Appropriate reimbursement: Accurate & complete documentation is necessary to receive appropriate reimbursement for care delivery

  • Accurate Quality Scores: Inpatient and outpatient are measured on various quality scores. It is imperative to capture accurate documentation that reflects the care delivered

  • Reduction in Denials: Denials are often the result of missing documentation to support medical necessity for the care provided

Key Challenges in the Outpatient Setting

  • Volumes of cases to review are significantly higher

  • Duration for episodes of care are considerably shorter

  • The type of service(outpatient setting) provided determines the guidelines, code set & payment methodology

  • Role of the non-physician documentation

  • Physician buy-in

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