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Tagged with: Value Based Reimbursement, CDI, Clinical Documentation Improvement, Population Health, Analytics

Three Areas Providers Need to Improve Outpatient Clinical Documentation to Meet the Demands of Value-Based Reimbursement

Peak Health Solutions - Aug 23, 2018


As value-based reimbursement continues to expand, providers will need to develop better documentation patterns where ever they practice. Improved documentation will help physician practices and acute care centers improve reimbursement, but consistent, quality documentation can also help both groups provide better patient care.

Historically, physicians in outpatient settings have focused on a simple approach. A physician who has a patient with a chronic condition, diabetes, for example, has called it diabetes and coded it with a simple diabetic code. If that same patient is later admitted to a hospital due to diabetes that is out of control or diabetes due to a manifestation, there will be a disconnect between the way the hospital codes the patient and the way the physician does. In short, the physician has not been given proper credit for treating a patient with a chronic disease.

There are three main areas where providers can work to improve outpatient CDI to get the most from value-based reimbursement:

The first is analytics. Historical data should be examined to establish patterns. Quality metrics, claims data, charge history, and other elements should all be evaluated to determine strengths and weaknesses in the documentation. Once areas that need work are identified, providers can focus on specific areas of improvement to ensure that their data is as robust as possible.

The second is population health. Health plans have focused on populations with common traits for some time to establish patterns of what works and what doesn't. Large health systems are also working to make this a component as a part of the communities they serve, and smaller hospitals and acute care centers should follow suit in their outpatient settings. By focusing on data from groups, providers can do the same and adjust their health management programs to add value versus the traditional approach of adding volume.

The third area CDI can make a difference for providers is billing. Physicians need to be explicit in their documentation so that billing is accurate. The more specific clinicians are in documenting their diagnoses, the easier it is to justify medical necessity for testing or the possible escalation of treatment if needed. This approach helps providers get reimbursed more accurately, but it also does what value-based care is designed to do in the first place. It puts the focus on the patients and what physicians can do to help their patients live healthy lives.

Outpatient settings are still playing catch up in the CDI space. Physician groups that provide outpatient care may work in the same hospital facilities where CDI is commonplace, but in an outpatient setting, the processes are different. Patients are in and out more quickly, and of course, coding and billing are different as well. With less documentation and shorter timelines, outpatient clinical documentation is harder to improve, but necessary in the age of value-based reimbursement. Without proper documentation, providers are leaving significant money on the table.

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Posted in: Value Based Reimbursement, CDI, Clinical Documentation Improvement, Population Health, Analytics

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