10 Ways Tech-Driven CDI Benefits Outpatient Practices

Technological advancements in Medicine have facilitated multiple services and surgical procedures, traditionally performed as an inpatient, in migrating to an outpatient setting.  This transition coupled with the shift in reimbursement from fee-for-service to value-based models necessitate extensive documentation of patient encounters in outpatient settings for coding and reporting.  Technology-driven solutions such as RevCDI-led coding from Reventics significantly lower the administrative burden of meticulous re-documentation the EHR requires for outpatient coding while promoting compliance and improving revenue. 

Implementing RevCDI-led Coding Solution: 

1. Ensures Emergency Physicians capture the right severity and acuity of problems, as ED physicians are always thinking about the worst, but often forget to document it.  RevCDI™ guides physicians to document the right keywords to support the medical necessity of the visit, testing, and treatment. 
2. Benefits Primary Care Physicians by performing chart reviews utilizing RevCDI™ and providing timely consistent feedback to accurately record patient’s history, exam, care coordination, etc.  These support coding to highest level of specificity, improve charge capture, define patient risk for risk-based contracting, and increase wRVUs. 
3. Guides Infusion Center Staff to accurately record order for service, type of infusion, infusion route, infusion site, start and stop times of infusion, and staff details for ideal CPT coding and reporting.  RevCDI™ educates nursing and ancillary staff on latest documentation requirements to support compliant CPT coding for infusions. 
4. Educates Independent Diagnostic Testing Facility (IDTF) Personnel to differentiate documentation requirements between screening and diagnostic procedures and ensures they document the specifics of findings to support the medical necessity of procedures/tests performed for CPT and HCPCS coding. 
5. Supports Ambulatory Surgical Center Staff to record the medical necessity for procedures to meet the requisite surgical CPT, ICD, and HCPCS Level II requirements.  RevCDI™ ensures correct procedures are reflected and helps create detailed procedure notes to improve wRVUs. 
6. Assists Wound Care Physicians to capture and track all necessary elements of a wound diagnosis consistently across continuum of care such as cause of wound, wound location, laterality, wound type (for example - trauma, ulcers, non-healing surgical wounds, etc) to assign precise CPT codes. 
7. Enhances ICD, CPT, and HCPCS Coding compliance by working with physicians to record diagnoses to highest level of specificity supported by clinical evidence leading to precise assignment of ICD codes impacting HCC and RAF scores.  RevCDI™ helps capture all relevant data to define procedural specificity in an E&M setting for compliant CPT and HCPCS coding. 
8. Improves Reimbursement by empowering physicians with relevant data to enhance the quality of documents to align with compliant coding and reporting standards to avoid claims denial, audits, and regulatory sanctions while promoting compliance through accurate level coding. 
9. Ensures Quality Scores are accurately reflected through excellent documentation of all services furnished in an outpatient setting to determine the need for quality improvement activities, subsequently increasing value-based reimbursement. 
10. Benefits Turnaround time (TAT) and Staffing by providing a well-established system in place for chart reviews to be performed immediately after the visit and before billing as concurrent reviews are not possible, while also compensating for reduction in staff by leveraging technology and increasing productivity. 

Conclusion 

With footfalls to outpatient practices increasing by 14% in the past decade and urgent care practice market set to grow 23% exceeding $26B by 2024, outpatient practices are invaluable places to implement a CDI solution.  RevCDI uses a clinically focused and analytics-led approach to identify clinical documentation improvement opportunities at the chart level and non-intrusively provide specific feedback to physicians both prospectively and retrospectively improving Critical Care, HCC, and MDM documentation, leading to increased compliant revenues.