Q&A: Measuring CDI specialist productivity

Q: Our CDI program is three years old and our administration still questions our productivity goals. Initially we set benchmarks at 90-95% coverage rate of Medicare/Managed Medicare; 20-25% query rate; 90% response rate and 80% agree rate. Since census varies, we also established goals of 10 or more new reviews per CDI specialist per eight-hour shift with re-reviews every 72-96 hours.

Are there newer/established benchmarks that programs should strive for? What is an acceptable number of reviews per day per CDI specialist? Finally, should intensive care unit (ICU) patients have a higher weight as they usually require longer reviews?

As an aside, I did review the information contained in the ACDIS CDI Roadmap and found it helpful.

A: We’re glad you took the opportunity to review the CDI Roadmap materials. The Roadmap committee and ACDIS team conducted extensive research in compiling the documents. The Phase I section of these materials includes a White Paper regarding variables affecting productivity and an example document of how one CDI department determined its productivity expectations. Here are the links to those documents:

•  “Variables affecting standardization of CDI staffing and productivity”
• “Productivity and staffing example”

Remember that the total number of full-time equivalent staff members your facility hires depends on:

1. Payer types reviewed
2. Total discharges
3. Accessibility of medical record
4. Software available to the CDI staff (e.g., encoder)
5. Other documentation duties and responsibilities assigned to the CDI staff

Productivity measures must be determined according to your individual CDI department.  There is too much variability among CDI departments when you consider their role within an organization, their mission statement (e.g., revenue enhancement or quality improvement), and their available resources to create standardized expectations.

CDI departments frequently use metrics recommended by the consulting group which assisted with initial implementation. As a CDI department matures, however, these metrics may need revision.

For example, as a CDI professional becomes more seasoned he/she becomes more proficient with conducting reviews and issuing queries. A manager should expect staff query agreement rates and coding agreement rates to increase over time, but you would never expect those agreement rates to reach 100%. An agreement rate of such extent is suggestive of physician submission rather than support.

In response to your initial question, however, I think the goal of 80% provider agreement rate could be pushed to 85% due to the maturity of your CDI department.  It is reasonable to expect the provider agreement rate to increase as both the CDI department and the CDI staff gain experience and develop relationships with the medical staff.  It is often helpful to measure physician agreement rates as both a departmental metric and for each individual CDI specialist.

I typically don’t recommend a metric for the volume of queries expected as this can lead to a focus on the quantity of queries rather than the quality of the query.  Additionally, there is variability within medical specialties as some, like cardiology, have more query opportunities than others, such as orthopedics.

The types of queries should increase in sophistication as a CDI department/CDI specialist matures. Queries should shift from simply asking for increased specificity (i.e., obtaining clarification congestive heart failure specificity as systolic or diastolic) to being able to identify vague and missing diagnoses that otherwise, would not be coded (i.e., recognizing clinical indicators of shock).  These types of queries are often more complex to develop and require provider agreement/support so they may result in fewer queries and a lower volume of reviews.

I encourage CDI managers to review the types of queries being asked by the CDI staff to ensure growth of the CDI specialists in their roles.  Query reviews and analysis should not simply ensure individuals comply with query guidelines.  In order for a CDI department to remain viable, the CDI specialists need to educate the medical staff regarding documentation opportunities that accurately represent the complexity of the patient’s condition with terms that can be adequately captured by coding.  The goal is for the coded record to precisely reflect the provider’s intent and the use of hospital resources.

The volume of follow-up reviews would be greater in a CDI department focused on quality metrics (SOI/ROM) compared to those focused on reimbursement (CC/MCC capture).  A  focus only on CC/MCC capture limits the number of reviews because once those conditions are captured (thereby, “maximizing” the reimbursement) no additional reviews are required as the record is complete, allowing the CDI specialist time to review other records.

On the question of record reviews for ICU patients taking longer than other reviews, again I’m afraid the answer is “it depends.” If the CDI department’s focus is reimbursement, these cases are typically maximized within the first two reviews so additional reviews are not necessary. If the focus is quality, I can see where these records can be cumbersome and require additional time and CDI staff focus.

In my previous career as a CDI manager, I did not measure staff members by volume of reviews. I believe the value of CDI efforts comes from their relationships with the providers. The value of CDI is not the number of records they review and “pre-code,” but rather in CDI specialists’ ability to change the documentation behavior of the medical staff.  In my opinion, that is best accomplished by interacting with the providers—a more time consuming endeavor than simply reviewing a record. If you change the behavior of one provider, you have improved the quality of many future records. Conversely, a single query typically allows CDI professionals to improve one record at a time.

Remember coders have always queried physicians, the concurrent nature of CDI efforts provides real-time feedback to providers. That is the value of CDI efforts within a healthcare system. This is where the success of CDI efforts lay.

I know this may be a tough sale to administration who like to measure productivity, but the measurement of outcomes rather than the process (e.g., the number of records reviewed) may be a more successful approach and result in higher staff satisfaction.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, answered this question. At the time of this article's original release, she was the CDI Education Director for HCPro Inc.