sponsibility may fall on HIM to obtain this knowledge if
they don’t already possess it.
What they bring to the table: A hospital director or vice
president of quality can explain how HCCs and condition
categories affect hospital quality measures. An ambulatory
director or vice president of quality can explain how these
same codes affect ambulatory quality programs.
4. IT/project manager. An IT-savvy project manager can
help the organization capitalize on electronic health record (EHR) technology as it ventures into outpatient CDI.
For example, he or she can activate HCC registries to identify patients with gaps in diagnoses and risk scores, build
physician-specific diagnosis preference lists that include
common HCCs, redesign workflows to maximize efficiencies, and develop IT tools to help physicians capture HCCs
more easily. In some cases, the manager of ambulatory
quality or HIM director may be able to serve in this role.
What they bring to the table: An IT/project manager can
help leverage technology and explain the logistics of executing the outpatient CDI program and how the EHR will
enable a return on investment.
Focus on What Matters Most to the C-suite
The C-suite doesn’t need to know all of the intricacies of RAF
score calculations. Instead, deliver a high-level message that conveys how outpatient documentation affects inpatient reimbursement. They need to understand that HCCs included on outpatient
claims for face-to-face visits affect hospital risk-adjusted value-based payments. This is important because inpatient documentation of HCCs and condition categories are sometimes lacking.
When calculating population risk, the Centers for Medicare and
Medicaid Services (CMS) looks back at outpatient claims over
a 12-month period prior to the inpatient admission. Outpatient
claims can fill in the gap, allowing organizations to get credit for
HCC and condition category capture.
The C-suite also needs to understand that some HCCs and
condition categories don’t risk adjust and positively impact the
readmission reduction program or bundled payment programs
unless providers document them before an inpatient admission.
Examples include chronic kidney disease (stages four and five),
diabetes and associated complications, and hemiplegia. This is
something that members of the C-suite must understand because it reiterates the importance of outpatient CDI.
How to Obtain C-suite Buy-in
for Outpatient CDI Programs
Figure 1: HCC/Risk Adjustment Financial Impact Example
IF A CONTRACT was for $700 per member/per month (PMPM) with a risk score increase of 6. 9 percent, then the projected
gross impact would be $4.9M (Scenario 3) if results of 57 percent HCC opportunity across 8,500 members continues through
the year. Note: Requires information regarding contract details.
Based on 1.0 benchmark RAF and $700 PMPM. Gross revenue impact captures both revenue at risk for not capturing conditions that were previously captured and new revenue for capture of new conditions. Net impact is based on contract terms.
GROSS REVENUE IMPACT BASED ON FINDINGS AND EXTRAPOLATION TO 8,500 MEMBERS