Hospital Impact: 4 tips for clinical documentation improvement in ambulatory settings

Nurse with a clipboard
"Ambulatory CDI” has become a common topic of conversation in the clinical documentation improvement world, but not everyone agrees on what it means.

headshot of Jon Elion

The Merriam-Webster dictionary defines “bandwagon” as

  • an 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,
  • 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 people what they mean when they mention it, I am not able to get a discrete answer.

Narrow the scope

My own approach to the conversation is to begin by narrowing the scope of the discussion. For example, I use the term “ambulatory” rather than “outpatient” to define the patient visits. While the distinction may seem arbitrary, I use it to refer to patients who are coming to a hospital-affiliated facility for healthcare, and who are electronically registered in the hospital information system (HIS), of which the electronic medical record is one major component. This eliminates office visits to private practice physicians who use their own medical record and practice management systems, and who typically do not send patient registration and demographic information electronically.

I also 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 healthcare provider during the visit.

Furthermore, I eliminate chart reviews for the purpose of auditing or improving documentation for a clinician’s evaluation and management coding. This is a perfectly valid pursuit, but is generally considered, managed and measured differently than CDI that focuses on hospital reimbursement.

Finally, I eliminate a common area of confusion that includes national and local coverage determination 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! That leaves a class of visits in which a patient is electronically registered to see a healthcare provider at a hospital-affiliated clinic. To date, everyone I have spoken to on the subject seems to agree with that definition.

Better define patient visit

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. It’s much better defined in the inpatient area. 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 “recurring” 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 treatment as wound care, IV therapy, physical or occupational therapy, etc. Bills are not sent each time the 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.

4 factors to consider

So, before you jump on the “ambulatory CDI” bandwagon, here are a few points 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 recurring visits.
  • Be specific about what you want to accomplish and how you will measure your progress.

Jonathan Elion, M.D., FACC, is a practicing board-certified cardiologist in Providence, Rhode Island, and an associate professor of medicine at Brown University.