Updated on: October 17, 2017

Outpatient CDI Hacks to Improve Risk Adjustment Profiles

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Original story posted on: October 16, 2017
Using the phrase “Hx of” and substituting “F/U of” will  make a difference to the risk profile of outpatient providers.

Lately I have been getting more requests from physicians to speak to them about outpatient clinical documentation improvement (CDI) and how to ensure that their risk adjustment profiles accurately reflect the care they are providing. 

Physicians are really interested in outpatient CDI since this can directly impact their quality scores and reimbursement. Risk-adjustment coding impacts many different types of insurance products, such as Medicare Advantage, Medicaid, and Patient Protection and Affordable Care Act (PPACA) plans, and many providers are now in shared savings agreements. Beginning in 2019, risk adjustment will be included in the Merit-Based Incentive Payment System (MIPS). Currently, many of the Advanced Alternative Payment Models (AAPMs) have risk adjustment as part of their methodology as well. 

So, what can a provider do? It is impossible to memorize all the rules and diagnoses related to the different risk adjustment models. The key to success in outpatient CDI is to teach providers specific tips to help them succeed. I like to call them CDI hacks, as this appeals to the more technologically savvy generation. I have compiled a list of different tips for providers and thought it would be interesting to share one of them with you. 

One of the first tips I share with providers pertains to the phrase “history of” or “past medical Hx of.” I tell them to stop documenting this phrase! How many times have you seen a provider note begin in this fashion : “Mrs. Jones is a 75-year-old female with a PMHx of systolic CHF who presented today with SOB.” 

I see this all the time! For the outpatient coders reading this, you know that we are not allowed to code the diagnosis of systolic congestive heart failure (CHF), as it is documented as a past medical hx. This means that the CHF has resolved and can no longer be coded as active, unless the provider makes it clear that the shortness of breath (SOB) is due to CHF. When I tell physicians or other providers this, they get very upset!  

So my tip is to teach providers to use the phrase “F/U of.” For our previous example, we could say “Mrs. Jones is a 75-year-old female who presented for f/u of systolic CHF and c/o SOB.”  

Just removing the phrase “Hx of” and substituting “F/U of” will make an enormous difference to the risk profile of outpatient providers, regardless of whether they are primary care providers or specialists. And please remember that this isn’t just for physicians – this affects certified registered nurse practitioners (CRNPs), physician assistants (PAs), physical therapists, psychologists, social workers, and many other providers whose documentation can be used for risk adjustment.   

For risk adjustment, the documentation must show that each diagnosis is being monitored, evaluated, assessed, or treated. If the documentation supports the diagnosis, then the diagnosis can be put on a claim and used to gauge the risk adjustment score of the patient.

So, share this hack with your providers – stop documenting “Hx of” and use the phrase “F/U of” instead.
Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Adele L. Towers, MD, MPH, FACP

Dr. Towers is the senior clinical advisor for UPMC Enterprises. She is directly involved in the development of healthcare-related technology, with emphasis on use of Natural Language Processing (NLP) for risk adjustment coding and use of clinical analytics to optimize clinical performance. Prior to this role, she has served as the medical director for health information management (HIM) at UPMC, with responsibility for clinical documentation improvement as well as inpatient coding denials and appeals.