Productivity: Impact vs. # Chart Reviews/Query Rates/Physician Response Rates

ginpin

As a DocSpec.for the past 4 years, I have become quite familiar with the important metrics to evaluate a DocSpec’s productivity. In the beginning the primary focus was on number of chart reviews, query rates and the physician response rates per month, with very little emphases on the individual’s financial impact. There are five DocSpecs , including me, in our department and the monthly impact has been reported as the“total impact” for the whole group and not divided between individuals.
Now with the ever-changing cost of medical care and decrease in reimbursements, the focus has shifted to individual monthly impacts. Recently 2 of our DocSpecs were recognized for their total contribution to the impact for the past year.
I am concerned about this new metric because some units have more opportunities to make a significant difference in the impact: CVR/CVO/ICU vs. Med/Surgical.
How do other CDI programs measure the Monthly Impact Report: as a “total” for the whole department or separate individual impacts? Do you rotate your staff to the different areas for equal opportunity to generate more individual impacts or do you allow the DocSpecs. to remain in their areas of expertise?
Any advice would be appreciated.

cmorell

Impact reports are very subjective because one could always ask "would the coder have picked that up on the back end anyway?". That is why this is best as a team effort. The only way in my opinion to measure the success of a CDI program is to not only evaluate monthly metrics but review on a yearly basis. The metrics should be the number of queries, doctor response rate, charts reviewed but what should be happening is that you will have a more complete and accurate medical record. The type of patients that are admitted (we had runs of gastrointestinal illness and we always have a million chest pain, abdominal pain, syncope etc) give the opportunity for clarification. The ICUs have greater opportunity for queries that may generate MCCs or change the DRG but equally important is the med surg floors and the unspecified CHF or symptoms diagnoses that need a "due to" link by the physician. Medical Necessity is going to become so important and when those charts are reviewed and monies are taken back. Especially if they start taking it from the physicians for lack of medical necessity based on documentation, then Documentation Specialists will become golden.
In my opinion, the problem is the "RAC threat" it is not real, its becoming mythical because the doctors have heard about it for so long but have not seen it, they don't really believe it.
If someone is leaving thoughtful queries that help to justify length of stay, utilization of resources, medical necessity and the doctors answer rate is improving and they contribute to ideas to continually educate the physicians about the program then you've got yourself a gem!
A program needs to be focused on severity of illness and risk of mortality. That will impact your risk adjusted mortality scores and those of your physicians. Focus on SOI/ROM and the money will follow. It will help your CMI, just as impacting those questionable medical necessity cases will. If the doctors write more information, that can change the codes and possibly the DRG. Without it, the whole stay might be denied.
All of this good documentation should help your blended rate as well which will make the administration happy because that will mean more money.
To measure/monitor each CDI/CDS, your supervisor should check some of the charts each CDI has reviewed and if there are opportunities that are missed, that is a great educational case study and a chance for future success.
The CDI field is opening up wider each and every day to include outpatients and medical offices, I hope companies don't make this all about the money and develop monetary metrics and reward based on that, Medicare will spank them hard!
If you don't already attend chapter meetings and national meetings, you need to start! Our CDI Sisters and Brothers and our support system of ACDIS, AHIMA and physician advisors like Dr. Kennedy, Dr. Haik, Dr. Gold etc. will give you more confidence and help you grow.
Happy Queries!

NormaB

Currently we are still reporting our impact as a "team"of two.

I do appreciagte your concerns. The CDS who has the medical floor does not have as great a chance at impacting their cases financially. An MCC on a mediical case may gain a finacial impact of a few hundred dollars to $1500 but a surgical case is usually always impacted by more. To me it's like comparing apples and oranges.

More days I find myself tweaking documentation which will not impact the overall DRG financially but will improve the overall documentation.

Rotating assignments might assist by giving each CDS an opportunity to work on the "money floors". But we are supposed to be about quality documentation not in competition over who "makes the hospital the most money".

Our case managers have been doing the same thing. They are in competition over LOS and financial impact. But what about the case manager who gets the floor with the "placement" problems? That's not fair to them.

I know CDS's who keep a running tally of every dollar they impact the bottom line. Its a safety measure in these economic times when budget is being finalized and management may be asked to cut staff.

I'm not sure of the answer yet. Money is something you can measure. I've heard it mentioned on this sight that if the focus is on quality documentation the financial impact will follow. And I do believe that to be somewhat true. But I also know that not all quality documentation will impact equally financially. Does that make sense?

And if you answer to money people that's how they measure success.

Our department falls under the financial umbrella. So does our Case Management department. What division is your department responsible to?

It would be interesting to see what areas financial vs, quality we report to and if the thought process of those areas dictate how we do our jobs.

cmorell

I think part of the problem is that this program was marketed to
administration as a way to make more money. So they buy in and are expecting
results and when the results aren't what they were promised they are told
its not all about the money.
It shouldn't be about the money it should be about an accurate medical
record. But money isn't a dirty word. We should be fairly reimbursed for the
care we give

dallend@einstein.edu

I am reading these posts and I am feeling lucky that our program has matured to a point where we are not counting every dollar that each query brings in.
In fact, on an average 4-8% of our queries truly impact DRG reimbursement. That includes concurrent and post discharge queries. We impact ROM/SOI more than DRG - although our software cannot produce those numbers. When I run the stats and I look at the comments we enter, mostly for post discharge queries and 2nd level reviews - it is ROM/SOI that is impacted.
We do not select DRGs any longer when we review charts. We document the principal diagnosis on our worksheet. When we reconcile our attestations and worksheets we evaluate the impact of our query. We do not track agrees/disagrees with coders. If we feel that a diagnosis is missed or we have a question regarding the coding the chart is returned to the coder or sent to the compliance manager for review (they are our second level reviews).
Our management reviews the CMI on a monthly basis and they look at SOI/ROM. Our program is 8 yrs old and we have made a definite impact through the years.
I think the fact that the physicians know we are reviewing charts helps - I have seen dramatic improvement with our surgery dept and more timely responses to the queries we leave for our surgeons.
We report to the HIM director and work closely with our coders and compliance manager.
Our ultimate goal is a clean chart.

ginpin

Thank you for your feedback. This certainly reinforces my philosophy of what the “ultimate goal” of the CDI program is. I attended a Boot camp 2 yrs ago in Atlanta and the major focus was “quality documentation” with special attention to SOI and ROM. I left with a totally new perspective and fresh ideas on what my role as a CDS is. However, my experience was met with deaf ears. I believe that the bottom line will be emphases on the money. There are some CDIs in our department that are more focus on the money aspect and the number of charts that were not reviewed. I agree with your comparison of “apples and oranges” in regards to the medical and surgical units and their potential to generate impact. You are right. It is not fair, as each patient record is a variable in itself. I do not want to be the type of CDI that opens a record and automatically thinks “show me the money”. I agree that not all quality documentation will impact equally financially. It will be interesting to see how these economic times will affect our roles as CDIs. My department is under Case Management; with very little interaction with HIM.

Regina McCroskey, BSN
MRMC Ocala, Fl.

NormaB

Your program sounds like what a CDI prgram should be aiming for!