• HQM

Why OPCDI is important

According to the 2017 Medicare Payment Advisory Commission Report to Congress, ”Outpatient payments rose by about $4B because volume increases, and the continued shift of services from lower cost physician offices to higher cost hospital outpatient settings.”


Strategic advantages to expanding CDI to the Outpatient Setting

•Affordable Care Act (ACA) driving to implement healthcare reform with a focus on quality outcomes, affordability and access to care. Key components include:

•Transition to value-based payment

•Advance care delivery through innovation

•Improve information dissemination including transparency on cost and quality for consumer decision making

•More regulatory oversight - OIG’s work-plan:

•Two-midnight rule

•Medical necessity of services

•Unbundling services

•Coding pair edits

•Improper use of modifiers


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 specificty

•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








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