Clinical Documentation Improvement (CDI) in an Outpatient Setting

Course Description:

Developing an Outpatient Clinical Documentation Improvement (CDI) program represents a pivotal step in the ever-evolving landscape of healthcare. As the healthcare industry continually adapts to the changing demands of quality, value-based care, and accurate reimbursement, the need for robust outpatient CDI initiatives has never been more pronounced. With the increasing shift towards outpatient settings, ambulatory care, and telehealth services, it has become evident that outpatient CDI programs are not just desirable but imperative to ensure the provision of high-quality patient care while maintaining the financial viability of healthcare organizations.

The contemporary healthcare ecosystem is undergoing a transformation that prioritizes not only the quantity of care delivered but, more crucially, the quality of care. Outpatient settings, such as clinics, medical offices, and telehealth platforms, have emerged as critical components in the continuum of patient care, catering to a diverse range of medical needs. While the inpatient CDI programs have long been established, the expansion of these principles into outpatient domains signifies a dynamic shift towards a more holistic and comprehensive approach to clinical documentation. The core objective of an outpatient CDI program is to enhance the quality, accuracy, and completeness of clinical documentation in these settings, ultimately resulting in improved patient outcomes, regulatory compliance, and financial sustainability.

One of the primary catalysts behind the need for outpatient CDI programs is the intricate web of reimbursement models within healthcare. The transition from fee-for-service to value-based care has placed increased emphasis on clinical documentation to accurately reflect the complexity and severity of patients' conditions. This shift is pivotal in ensuring that healthcare providers are adequately compensated for the services they render, as well as in maintaining regulatory compliance. Outpatient CDI programs bridge this gap by training healthcare providers, clinical documentation specialists, and coders to collaboratively document patients' conditions and care processes with precision, ensuring that reimbursement aligns with the actual level of care delivered.

Moreover, the expansion of telehealth and remote care has further accentuated the importance of outpatient CDI. As the world witnessed a profound acceleration in telemedicine during the COVID-19 pandemic, the need for comprehensive and precise clinical documentation in these remote encounters became glaringly evident. Telehealth encounters present unique challenges in terms of documentation, as providers may rely solely on virtual interactions and electronic health records. Outpatient CDI programs are essential in empowering healthcare professionals to effectively communicate patient conditions and ensure data accuracy, even when the traditional face-to-face visits are replaced by video consultations or remote monitoring.

An outpatient CDI program also aligns with the broader healthcare imperative of reducing the risk of medical errors and ensuring patient safety. Accurate clinical documentation provides a comprehensive picture of a patient's medical history and current health status, enabling clinicians to make informed decisions, coordinate care effectively, and reduce the risk of diagnostic and treatment errors. By facilitating the capture of a patient's full clinical complexity, outpatient CDI promotes patient safety as a fundamental tenet of the program.

In conclusion, the development of an outpatient CDI program is a forward-thinking response to the dynamic changes in healthcare delivery and reimbursement models. As healthcare continues to shift towards outpatient settings and telehealth, the need for comprehensive clinical documentation has never been more critical. These programs enhance patient care, improve financial sustainability, and align with the overarching goal of delivering high-quality, value-based healthcare. The implementation of a well-structured and robust outpatient CDI program represents a strategic investment that not only ensures accurate reimbursement but, more importantly, serves as a cornerstone in the delivery of exceptional patient care in the modern healthcare landscape.

Learning Objectives:

• Recognize components of outpatient CDI programs
• Perform CDI Compliantly
• Identify Documentation Requirements
• How to develop an outpatient CDI program
• Determine who should be involved in your outpatient CDI program
• Implementing your outpatient CDI plan
• Getting clinician buy-in for your outpatient CDI plan
• Monitoring ongoing outpatient CDI Efforts

Areas Covered in the Session:

• Components of CDI programs
• CDI in an Inpatient vs. an Outpatient Setting
• Performing compliant CDM
• Documentation
• What you can and can’t do as part of your CDI program
• Measuring success of your CDI program
• Live Q&A session

Suggested Attendees:

• CEO, CFOs and CMOs
• Billers
• Providers
• Care Coordinators
• Physician Practice Managers
• Coders or Coding Management
• HIM Directors and Staff
• Authorization/Referral Team members
• Clinicians
• Physicians
• Mid-Level Providers
• Clinical Documentation Specialist
• HIM Personnel
• Administrators
• Auditors
• Claims Adjusters
• Reimbursement Staff
• HIM Management
• Quality Managers
• Coding Auditors

About the Presenters:

Betsy Rios is a seasoned professional who has over 25 years of experience in coding and RCM, Healthcare Receivables management. She has managed coding and RCM at freestanding clinics, hospital based clinics, Rural Health Clinics, group clinics as well as Critical Access and PPO Hospitals. Betsy started in Home Health as a biller and worked her way up to Director of Reimbursement at a home health chain with offices across the country. She then transitioned into hospital and professional billing and coding, managing these functions for facilities and clinics. Betsy went to work at a national coding company as a professional auditor and was promoted to Pro Fee Coding Manager, then became the Revenue Cycle Operations Manager. Betsy now focuses on consulting and assisting smaller facilities and clinics with coding and revenue cycle issues.  She is very active in the rural health community and says that solving inefficiencies is her passion.

Additional Information:

After Registration: You will receive an email with login information and handouts (presentation slides) that you can print and share with all participants at your location.

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to talk and hear clearly

Can’t Listen Live?

No problem. You can get access to an On-Demand webinar. Use it as a training tool at your convenience. For more information, you can reach out to the below contact:
Toll-Free No: 1-302-444-0162
Email: care@skillacquire.com

Snippet From Our Previous Session:

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Email: care@skillacquire.com