Q&A: How to reconcile additional responsibilities, productivity expectation

Q: I am the only CDI specialist in our 150-bed facility. I have held the position for three years, and am the first one to do so helping to build the position from the ground up. Being the only CDI, I am on several committees, responsible for continual physician education, continuing medical education presentations. I am a constant clinical resource for our inpatient coders, and do all payer reviews everyday which amounts to between 25 and 40 reviews and re-reviews per day.

We have no coding compliance person at this time and I have been asked to review charts for the coders which involve single CC/MCC and/or those that may have a complication as well. My query rate has since dropped and I am being asked why. I feel helpless. Are there standards for CDI productivity for a one woman show?

A:  I have worked in small hospitals for most of my nursing career, and as in any institution when you display your value, skills and talents, administrators begin to put more on your plate--at times overloading it. Unfortunately, in a small hospital there are less “plates” at the table and it can be easy to become overwhelmed.

The role of the CDI is an important one, and your organization sees that because they wish to have you involved in so many different endeavors. Your description above reflects the position I held in CDI for approximately four years before my organization decided to further invest in expanding the number of CDIs.

There are many reasons that might lead to a drop in query rate, one being that your physicians are learning. With the initiation of a program, the query rate is often higher and tends to level out as the physicians learn about the needed documentation. This means you have done such a great job that the documentation issues are less, requiring less queries.

On the negative side, if you are feeling rushed to complete reviews the quality of your reviews may have dropped. As you know, it takes time to dig thorough the record to find potential opportunities. If time is an issue, we might not ‘dive’ into the record as deep as we should. Since you are alone, it might be a good time to discuss how to prioritize accounts with your supervisor. Are there certain accounts that you may be able to pass over?

I love that you review all payers but when you are working by yourself, this may not always be a reasonable option. Do you review every patient every day? How do you decide how often to review or when you can stop the concurrent review process on a specific account? This would be a great discussion to have with your manager or leadership team.

Are you seeing a drop in other measures applied to your program? Is there a rise in retrospective queries? This would demonstrate that perhaps you are not catching such query opportunities up front. If there is no rise in the retrospective query rate it might mean that you a capturing query opportunity quite well. How is the physician response rate? CC- MCC capture rate? CMI? Are your other measures seeing a decline as well?

As for performing second level reviews for the coders, perhaps they could put a system in place in which another coder first looks at the record before it hits your desk, especially for those records in which there is only one CC or MCC. This might decrease the number of reviews you are required to do in these instances.

Take a look at the 2014 CDI Program Productivity and Program Structure Benchmarking Report published by ACDIS as well as other suggestions from the Association. This might give you some comparison, or offer tools that you can use when speaking to your manager. I understand creating new positions especially in smaller hospitals is next to impossible but the return on investment for CDI expansion is a positive one.

CDI practice can encompass a large variety of organizational needs from medical necessity to quality, core measures etc. It is important to not cast such a wide net that the person(s) performing the task cannot succeed. Also, if you are a member, the CDI Talk listsere is a perfect opportunity to “ask around” and see what others are being asked to do and with what resources.

I suggest after a little research you sit down with your management team and discuss what is the expected focus of your program? What is the mission and goals? Review your assigned responsibilities and ask assistance in prioritization of these tasks or perhaps identify others that could support you.

You should also consider the impact of ICD-10 on your organization. We expect coder productivity to drop up to 60% primarily due to PCS coding. The more investment up front in CDI, both to provide teaching and concurrent chart review, could help to ameliorate the impact of productivity drop. This is why many organizations (big and small) are increasing their numbers in the CDI department.

There were times when I felt quite overwhelmed too. It is difficult to be the sole CDI, as no one really understands what you do and why. And it is easy for all concerned to think adding just one more duty to the list won’t hurt. I had an excellent mentor when I started in nursing management several years ago. She taught me that when I was feeling overwhelmed and was handed a new responsibility, to respond “I am more than happy to take this on, can we discuss what task or responsibility I might be able to give up so that I might have the time to lend my skills and focus to this issue.” Smile when you say it, I was always amazed at how well it worked!

Editor’s Note: CDI Boot Camp Instructor Laurie Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps offered by HCPro visit www.hcprobootcamps.com/courses/10040/overview. This article was originally published on the ACDIS Blog.