How to tame the wild, wild west of ambulatory CDI

Healthcare leaders lose a lot of sleep about ambulatory clinical documentation and billing practices because of the wide range of documentation, patients, coding and billing requirements in the outpatient arena that differ from the inpatient setting. Driving improved financial performance in the outpatient setting is a #1 priority among senior hospital and health system leaders, according to a recent study conducted in collaboration between Nuance and HealthLeaders Media. I specialize in ambulatory clinical documentation improvement (CDI) and see administrators worrying about how to tame the Wild West. Here are my recommendations.
Enhancing revenue strategies in outpatient care for value-based payments

We are seeing a shift away from acute care treatment in favor of lower-cost outpatient or ambulatory care settings, due largely to the transition from volume to value-based care.  Hospitals are working to decipher the most appropriate care setting while maximizing quality outcomes, minimizing performance penalties and optimizing financial reimbursement. Given this shift, and the need to uncover revenue in the ambulatory setting, we surveyed 130 healthcare professionals (senior leaders, clinical leaders, operation leaders and IT) to uncover drivers, challenges and risks.

Provider organizations understand the importance of increasing outpatient revenues; it’s a top-of-mind priority among senior health system leaders. It’s managing the differing clinical documentation, coding, billing and payment methodologies requirements and strategies that make optimizing this critical source of revenue so daunting.


Physician practices & quality-based payments

Nearly two-thirds of leaders surveyed said improving outpatient care delivery and revenue, while transitioning to value-based payment (VBP), is a strategic imperative. Many also said the inability to recognize risk versus opportunity presented a significant challenge for them.  They cited insufficient support for physician practices in documentation, coding, and billing as one of greatest challenges to optimizing outpatient revenue integrity and compliance.

These concerns are not unjustified. Appropriate and specific documentation leads to correct coding, and is essential to accurate disease burden capture and carries implications for quality-based payments and population health management. Together, these are critical to preserving revenue integrity and transitioning to new payment models successfully.

Outpatient CDI - Drivers to Improve Financial Performance

We find our clients who tackle ambulatory CDI programs are adjusting to the wide range of documentation, coding and billing requirements in the outpatient arena and how they differ from the inpatient setting. Higher patient volumes and shorter encounter times – not to mention a shortage of qualified clinical documentation specialists trained in the unique payment methodologies in the ambulatory space creates a scary situation. With all these uncertainties, you  can see why healthcare leaders look at ambulatory CDI  as the Wild, Wild West. This is particularly true as it relates to risk-adjustment payment methodologies.

This explains why our research found outpatient care delivery and reimbursement a top concern; leaders understand that this “Wild West” can have a very negative impact on overall clinical and financial performance for an organization.

It comes as no surprise that nearly an equal amount of the survey respondents (62%) mentioned pressure to transition to VBP and better population health management (58%) as key drivers to their outpatient revenue priorities. The Department of Health and Human Services (DHSS) is watching this closely; this year 85% of all Medicare fee-for-service payments will be tied to quality and value, and by 2018 the agency will tie 90% of payment to this these metrics.

In addition to working with clinical teams, I work closely with healthcare CFOs. Financial performance is always at – or close to – the top of their list of business objectives. These leaders also are looking at risk-sharing models that link the cost and quality of care with shared savings, as they are a principal contributor to financial success.

The transition to value is taking hold. There are a number of things leaders can think about and prepare now that will help set them up for success and mitigate risks.

Read the full survey report, Taming the Wild, Wild West of Ambulatory CDI to Enhance Overall Hospital Revenue Strategies, here.

Read the report.

Read the full survey report, Taming the Wild, Wild West of Ambulatory CDI to Enhance Overall Hospital Revenue Strategies, here.

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Kimberly Hopey, PhD, RN

About Kimberly Hopey, PhD, RN

Dr. Hopey is the director of professional services at Nuance. During her 15 years of leadership at the hospital and health system level, she has gained widespread experience in Clinical Documentation Improvement implementing a highly successful and sustainable program from the ground up. She is now working closely with healthcare leaders to understand and mitigate clinical and financial risks in outpatient settings. Her expertise includes program/ process development and redesign, performance improvement and outcomes management, as well as, technology innovation and integration. She possesses extensive experience with managed care and governmental payers, revenue cycle operations, denial management, regulatory audits, and patient quality and safety.