Unlocking the Future of Healthcare: Why Outpatient CDI is the New Frontier in Accurate Clinical Documentation

In the latest episode of RCMchat, a podcast hosted by AGS Health, the spotlight was on clinical documentation improvement and utilization management. The host, Michelle Dawn Mooney, conducted a dialogue with Scott Entinger, CEO of CDI Answers, and Eric McGuire, Senior Vice President for Medical Coding and CDI Service Lines at AGS Health.

The conversation focuses on:

• CDI’s Role: Emphasized the criticality of accurate clinical documentation.
• CDI Challenges: Discussed issues like changing regulations and lack of support.
• Inpatient vs. Outpatient CDI: Highlighted the differences and the need for more education in outpatient CDI.

Entinger’s expertise comes from CDI Answers, a firm dedicated to recruitment and consulting in the realm of clinical documentation and integrity. CDI Answers works nationwide with health systems to elevate their CDI programs, rejuvenate existing ones, and provide education via their CDI Academy.

Meanwhile, McGuire supplements the conversation with his 25 years of experience in medical coding and CDI at AGS Health, a company providing comprehensive revenue cycle services with technology enablement.

The episode examined the influence of precise clinical documentation on utilization management and clinical documentation improvement. Entinger underscored the escalating importance of documentation in the context of utilization management. The primary objective is to validate inpatient stays, describe the severity of patient conditions, and ensure accurate patient transitions between settings.

McGuire agreed with Entinger, underscoring that erroneous documentation could cause increased denials and other challenges within an institution. With the healthcare industry moving towards value-based care, the demand for precise and specific clinical documentation is expected to rise.

The guests discussed the greatest challenges confronting CDI programs today. Entinger identified issues like mastering clinical terminology, dealing with ever-evolving coding concepts and regulations, aligning physician incentives with facility needs, and managing complex payer scenarios. This rapid change and rising complexity in CDI practices demand continuous education and training for healthcare professionals.

McGuire shared these sentiments, emphasizing a growing need to educate not just providers but also administrators about the importance of CDI and demonstrating the return on investment for CDI programs.

The conversation then explored the disparities and trends in inpatient versus outpatient CDI. According to Entinger, inpatient CDI mainly focuses on the inpatient Diagnosis Related Group (DRG) with additional quality measures like Patient Safety Indicators (PSIs), mortality, and readmission measures. Conversely, outpatient CDI, which deals with capitation involving Hierarchical Condition Categories (HCCs) for Medicare and Medicaid, and physician cost-efficiency measurements, is less defined and structured.

McGuire agreed, noting that while inpatient CDI is more structured and disciplined, outpatient CDI is akin to the “wild, wild west,” still defining its trajectory.

For more insightful discussions on enhancing healthcare operations, stay tuned for the next episode of RCMchat.