2. What HCCs do we currently capture for this population?
3. Howdoesthiscaptureratecompare withnationalbenchmarks?
4. What is the financial impact of an improved HCC capture
rate that’s on par with national averages?
5. How will an outpatient CDI program enable better HCC capture? With an outpatient program, clinical documentation specialists can focus on supporting capture of diagnoses that connect to an HCC. This approach can be done in a variety of ways,
but regardless of the approach the accuracy and possible increase in HCC capture will lead to more accurate and improved
risk scores. It is possible for organizations to improve RAF scores
by 15 percent or more even with limited resources, as the authors of this article have seen demonstrated at various healthcare facilities. For example, this was the case at Lakeland Health,
a healthcare organization based in southwest Michigan, who
saw a 15 percent increase in RAF scores the first year they expanded CDI into the ambulatory setting with limited resources.
Other Tips to Consider
When obtaining C-suite buy-in for outpatient CDI, HIM professionals can also use these strategies:
1. Leverage the value of your inpatient CDI program. How
has your inpatient CDI program affected quality metrics,
revenue, and utilization management? This can help establish a “proof of concept” for outpatient CDI.
2. Offer to perform an outpatient HCC pilot program. Using ex-
perienced inpatient CDI specialists and coders, focus on doc-
umentation improvement for target populations (e.g., patients
with diabetes or obesity). Once you’re able to make a signifi-
cant impact on RAF scores, continue to expand your efforts.
3. Conduct a patient-centered chart review on the outpatient
side to determine the extent to which HCCs are under-doc-
umented. These findings can support recommendations for
moving inpatient CDI programs into the outpatient setting.
Using these strategies, it doesn’t usually take leadership long
to realize the value proposition for outpatient CDI. The necessity of HCC capture—and its impact on ACO success—becomes
crystal clear. To ensure long-term viability, however, HIM must
be at the table to share their critical knowledge of the financial
and compliance aspects of outpatient CDI. ¢
James P. Fee ( James.email@example.com) is CEO and Sonia Trepina (Sonia.
firstname.lastname@example.org) is director of ambulatory CDI services at Enjoin.
Rachel Phillips ( RHPHILLIPS@LakelandHealth.org) is manager of coding and CDI at Lakeland Health.
No Conditions Reported
Some Conditions Reported All Conditions Reported Appropriately
Status/Condition Weight Status/Condition Weight Status/Condition Weight
80-year-old female .557 80-year-old female .557 80-year-old female .557
Medicaid Eligible .179 Medicaid Eligible .179 Medicaid Eligible .179
Diabetes (without manifestations) .118 Diabetes with CKD .368
CKD Stage 4.224 CKD Stage 4.224
History of CVA Hemiparesis following CVA .581
Heart failure not coded Heart Failure .368
+ Disease Interaction = Bonus
Factor (DM & CHF)
Total RAF .736 Total RAF 1.078 Total RAF 2.431
PMPM Base Payment $800 PMPM Base Payment $800 PMPM Base Payment $800
Per Member Per
$589 Per Member Per
$862 Per Member Per
Annual Payment $7,068 Annual Payment $10,349 Annual Payment $23,337.60
Figure 2: HCC Financial Impact in Coding and Documentation Improvement—
CMS Payment to Medicare Advantage Payer
Quiz ID: Q1818907 | EXPIRATION DATE: JULY 1, 2019
HIM Domain Area: Management Development
Article—“How to Obtain C-suite Buy-in for Outpatient CDI
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How to Obtain C-suite Buy-in
for Outpatient CDI Programs