Ambulatory CDI: What It is NOT
Feb 9, 2017
by Dr. Jon Elion

The Merriam-Webster dictionary defines “bandwagon” as:

  • a usually ornate and high wagon for a band of musicians especially in a circus parade
  • a popular party, faction, or cause that attracts growing support —often used in such phrases as jump on the bandwagon; or
  • a current or fashionable trend

I had to check the definition to make sure that I am using the word correctly when I say, “Everyone seems to be jumping on the ‘Ambulatory CDI’ bandwagon.” It has become a common topic of conversation in the Clinical Documentation Improvement (CDI) world, but most of the time when I ask someone what they mean when they mention it, I am not able to get a discrete answer.

My own approach to the conversation is to begin by narrowing the scope of the discussion as follows:

  • I use the term “Ambulatory” rather than “Outpatient” to define the patient visits to be considered. While the distinction may seem arbitrary, I use it to refer to patients who are coming to a hospital-affiliated facility for health care, and who are electronically registered in the Hospital Information System (HIS), of which the Electronic Medical Record (EMR) is one major component. This eliminates office visits to private practice physicians who are using their own medical record and practice management systems, and who are typically not sending patient registration and demographic information electronically.
  • We can further eliminate from consideration patients who are being registered at a hospital facility for diagnostic testing (such as an echocardiogram). In this case, while the patient has to register before the testing is done, there is no encounter with a health-care provider during the visit.
  • Next, we can eliminate chart reviews for the purpose of auditing or improving documentation for a clinician’s Evaluation & Management (E & M) coding. This is a perfectly valid pursuit, but is generally considered, managed and measured differently than CDI that focuses on hospital reimbursement.
  • After that, we can eliminate a very common area of confusion that includes National and Local Coverage Determination (NCD and LCD respectively) and Medical Necessity. While this is a common issue (I see it often for cataract surgeries in an Ambulatory Surgery Center), it should not be confused with CDI.

Phew! Now we’re left with a class of visits where a patient is electronically registered to see a health care provider at a hospital-affiliated clinic. To date, everyone I have spoken to on the subject seems to agree with that definition.

The next area of confusion seems to be the definition of exactly what constitutes a visit. I confess that this one caught me off guard. In the inpatient area, things are much better defined. I know when a patient gets admitted (although I still roll my eyes at the concept of a “bedded outpatient”!), and I know when the patient is discharged or transferred. The boundaries of a hospital visit are well-established.

But in the ambulatory world, it is not uncommon to have “re-occurring” or “open accounts” (they seem to go by different names at different facilities). In this situation, there is one account number for visits that may extend over many months for such things as wound care, IV therapy, Physical or Occupational Therapy, etc. Bills are not sent each time that patient is seen at the facility rather, one is sent periodically, or when the account or series of visits is officially closed out. There does not seem to be consensus about how this should be handled in a CDI workflow.

So, if you’re thinking of jumping on the “Ambulatory CDI” bandwagon, here’s a few things for you to consider:

  • Define the exact patient and visit categories that you think merit inclusion in a CDI workflow.
  • Determine how these patients can be identified by information in the HIS and its associated electronic messages.
  • Make sure that you can define your facility’s use of account numbers in open or re-occurring visits.
  • Be very specific about what you want to accomplish, and how you will measure your progress.

There is a lot of consensus still to be reached while we’re all sitting on the Ambulatory CDI bandwagon (hopefully not the one in the circus parade).  In a future blog I’ll discuss how Hierarchical Condition Categories (HCCs) can play a role and help to define how we can move CDI into the ambulatory world.

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