Some of the biggest ongoing discussions within HIM and the CDI specialist (CDIS) profession revolve around the areas of staffing and productivity. How many CDISs should a 500-bed hospital employ?
What criteria are used to determine how many CDISs are needed? What is a reasonable volume of monthly or annual reviews?
The problem with these questions is the extreme variability among facilities regarding the role of a
CDIS and what hospitals consider common daily tasks. A traditional CDIS is commonly thought of as a nurse who clarifies only those diagnoses that directly impact payment through DRG assignment. His or her tasks may include clarification of the principal diagnosis and identifying any secondary diagnoses that may result in CC or MCC assignment. Once a case has reached the highest possible
DRG assignment, the CDIS’s review on that case is assumed to be complete.
However, few clinical documentation departments fit this traditional model, and it should not be considered the industry standard. First, this model does not take into consideration additional duties performed by CDISs while they are reviewing the health record. These additional duties may include:
 Reviewing criteria of inpatient admissions to ensure they meet medical necessity
 Monitoring the correct verbiage for the patient status (inpatient or observation)
 Capturing additional diagnoses that do not impact MS-DRG assignment but do affect severity of illness (SOI)/risk of mortality (ROM) scores
 Reviewing for compliance with CMS quality indicators
Although it may seem reasonable to ask a nurse or HIM professional to perform these additional review functions, the skill sets needed to perform case management or quality reviews differ from diagnosis clarification only and may require review of different elements of the health record.
Secondly, concurrent record review on patient units is only a part of what the CDIS must accomplish during the record review process. The CDIS must know what charts to select for review and when to review the case in order to optimize his or her CDI priorities. In some organizations it can be challenging to locate or access the patient record, or the record may be incomplete, requiring multiple attempts to review it. Many CDISs do not have access to the same tools or possess the same experience as the coding staff within their facility, a situation that may require additional coding research during the review process, thus increasing the time spent on a particular review. In addition, some CDISs use stand-alone coding tools that do not save their encoder results and/or require input of demographics, requiring daily entry of the same diagnoses. As a result, the responsibility for establishing a working (or concurrent) DRG can be an additional time-consuming burden.
The query process is also a time-consuming activity both in developing the query and in closing it. An unanswered query can require frequent record checks for the additional documentation as well as

negotiation between the CDIS and provider. The amount of time a CDIS spends each week on queries can be highly variable. Factors which influence the amount of time spent on this task include:

The number of patient records reviewed

The number of queries generated for each record

The process for obtaining query responses concurrently and retrospectively
 Who is responsible for each part of the process

Accessibility of the health record and/or provider
The maturity of the CDI department and the cooperation of the medical staff can influence the amount of CDIS time engaged in physician education. Educational activities may include impromptu interactions with the medical staff on the patient care units, formal presentations with PowerPoint ® slides and educational tools as handouts, or auditing service line documentation to identify deficiencies. In order to be successful, CDI departments must also establish and maintain strong working relationships with other key departments such as coding, quality, and case management/utilization review. These interactions may consist of formal meetings, participating in interdisciplinary patient care meetings, or reconciling DRG assignment discrepancies with coding.
Lastly, CDI departments must often “prove their worth” through time-consuming manual tracking of a variety of metrics such as:

Number of queries left by physician (DRG impact vs. severity)

Overall response rate by physician (percentage of physician interactions)
 Number of queries impacting case-mix index (CMI) by physician and in total
 Number of queries positively responded to by physician and in total

Number of queries for principal diagnosis selection

Number of queries for secondary diagnosis selection

Number of charts reviewed
 How many times a chart was reviewed

Number of days before the chart was initially reviewed

DRG ratios with CDI and query impact

Average relative weight impact on cases
 Revenue attributed to CDI program
 Top 20 DRG volumes/month

Monthly case mix with results of focused DRG reviews

Productivity and specialty impact

As a result, ACDIS does not advocate for a specific one-size-fits-all formula for determining
adequate staffing and chart review productivity. Rather, ACDIS believes it is incumbent upon the individual hospital to make that determination based upon the goals and objectives of the CDI program, the actual scope of work of the program, and the core competencies and skill sets of the
CDIS.
Hospitals that wish to identify baseline productivity and staffing standards should consider the following variables when developing staffing ratios for their CDI program (note that this is not an allinclusive list):
1.
The skill sets and core competencies of individual CDISs. Skills that can influence individual
CDIS productivity include the following:

Critical thinking ability
 Mastery of clinical terminology and disease processes
 Verbal and written communication skills

Reading comprehension and retention of information

Understanding of coding rules and guidelines as well as where to seek clarification (i.e., coding clinics, nosology, etc.) for the identification of principal and secondary diagnoses

Understanding of MS-DRGs and/or APR-DRGs and/or DRG assignment

Level of experience with computers and typing speed
Why this affects productivity/staffing:
CDI is more of an art than a science, and it can take more than a year on the job for someone to attain proficiency as a CDIS. There is much trial and error when learning how to assign ICD-9-CM codes and working DRGs because each health record stands alone. In addition to the coding aspects of the CDIS role, the CDIS must be a “clinical content expert” within the medical specialty to which he or she is assigned. A CDIS who is expected to cover multiple specialties will require training on the nuances of disease processes for purposes of recognizing vague, missing, and incomplete documentation. This skill set differs from simply asking for clarification or increased specification of existing documentation. An experienced coder transitioning to a CDIS role may have an advantage with a strong knowledge of coding rules; however, this knowledge must be combined with the essential elements of practical clinical knowledge and familiarity with a wide array of different clinical disease entities.
Conversely, an experienced nurse transitioning to a CDIS role may have an advantage with a strong clinical knowledge, but would need to develop coding and DRG assignment expertise.

CDISs need to be comfortable with both their clinical knowledge and their coding knowledge before establishing credible relationships with the medical team. It takes confidence and skill to engage in a persuasive, objective conversation with someone who is viewed as a professional superior, and this unequal relationship can be intimidating. The most effective CDISs spend time cultivating a collegial, collaborative relationship with the medical staff.
2.
The focus of the program, including designated goals and objectives. The focus of a CDI program can include one or more of the following objectives:

CC/MCC capture with a focus solely on MS-DRG assignment

Reviewing diagnoses and procedures affecting SOI and ROM with a focus on APR assignment
 Positively affecting the organization’s mortality index

Obtaining thorough documentation of CMS quality indicators

Obtaining thorough documentation of patient safety indicators
 Reviewing the entire record for accuracy and completeness of all diagnoses and procedures regardless of payment impact

Collaborating with utilization review/management and case management to support the medical necessity of the level of care/setting and/or justification of the procedure as required by compliance with national coverage determinations and local coverage determinations

Achieving synergies of CDI that are of material benefit to the hospital and the physician in his or her business of the practice of medicine
 Helping physicians establish medical necessity for their services and code and bill appropriately
Why this affects productivity/staffing:
Looking for “one more thing” when you are already in the health record adds more to the review process than just the few minutes it takes to review the documentation.
Interpreting the medical record to support these different goals requires expertise in related but distinct disciplines—for example, knowledge of diagnoses that result in
CCs/MCCs; knowledge of diagnoses with an intrinsic SOI/ROM value greater than 1/1 and how different clinical diagnoses impact the SOI/ROM of other diagnoses; and knowledge of the quality measures for CMS and The Joint Commission, plus the documentation requirements for each.
In addition, these goals and focuses can sometimes contradict each other. For example, consider the diagnosis of acute respiratory failure. When acute respiratory failure is

documented following surgery, it can add an MCC to the MS-DRG; however, reporting ICD-
9-CM diagnosis code 518.81 in conjunction with an elective surgical procedure can result in a quality deficiency based upon postoperative respiratory failure rates.
The types of documents reviewed vary based on the focus of the program and the object of the review. For example, an initial review for CC/MCC capture would focus on the history and physical of the patient to identify chronic conditions that are still being treated and/or require greater specificity and identification of the reason for the admission. The intensity and depth of additional reviews will increase as the patient’s length of stay (LOS) extends beyond the associated geometric LOS for the associated working DRG in an effort to explain the increased LOS with acuity. An initial review for medical necessity would require an extensive review of outpatient documentation (including emergency room documentation) prior to the admission in addition to the history and physical, which may not impact CC/MCC capture. A quality review cannot begin until a working principal diagnosis is assigned as quality measure indicators are identified by ICD-9 diagnosis codes.
In contrast, a CDIS whose CDI program is focused on MS-DRG assignment alone can often
“close” a case in one review if the severity is great enough for the highest level of reimbursement to be reached, or if the case falls into a one-tier DRG (i.e., an MS-DRG that is not further categorized into “with CC,” “with MCC,” “with CC/MCC,” or “without
CC/MCC”).
3.
The political landscape of the organization, including the will of the administration and physicians.
Why this affects productivity/staffing:
The political landscape of the organization has a direct impact upon the productivity and staffing of the hospital’s CDI program. Questions that must be addressed and answered in determining the expected productivity of the CDIS include the following:

Does the general culture of the medical staff clash with that of the hospital administration?
 Is there strong physician and administrative leadership within the organization?
 Is there a physician champion within the organization that is well respected by the medical staff at large who can be an ongoing champion of the program moving forward?

What is the employment status of the physicians? For example, are the physicians employed by the hospital? Are they incentivized by Relative Value Units? Is there a

quality metric built into the compensation package? Do the physicians share in the gain as well as the pain?
All of these considerations have a material impact upon the productivity and effectiveness of a CDIS as he or she may need to devote more time to provider education, constructing clinical queries, and receiving timely responses from physicians.
4.
The degree of buy-in from physicians.
Why this affects productivity/staffing:
It takes time to win physicians over to the material benefits and merits of complete, impede CDI productivity. Circumstances may differ if your organization is an academic medical center.
5.
Initial and continuing education for staff. accurate, and effective clinical documentation in support of their clinical judgment, medical rationale, and medical decision-making. Those physicians who have a preconceived notion of clinical documentation as a necessary “evil” of medicine will likely
Why this affects productivity/staffing:
The healthcare industry is dynamic, and healthcare reform is driving revisions to reimbursement rules and regulations. One of the biggest changes is the impending transition from ICD-9-CM to ICD-10-CM/PCS. A CDIS should balance his or her daily duties with staying current on these ever-changing rules and regulations. A strong CDI department requires leadership dedicated to annual continuing education, and CDI staff should be aligned with the HIM/coding staff regarding changing coding practices. Training can reduce productivity, but a lack of training can result in DRG assignment discrepancies, which require frequent discussions between CDISs and coders as well as present compliance risks.
6.
The case mix of the hospital.
Why this affects productivity/staffing:
One of the basic principles of CDI programs is to ensure accurate MS-DRG assignment. An
MS-DRG can be one-, two-, or three-tiered, meaning patients can be stratified in as many as three different categories. Medical services that are single-tier or require a MCC for movement may be lower priority compared to services with multiple stratified DRGs.
Depending on available resources, an organization may review its DRG distribution to guide CDI assignments, especially if the organization has limited CDI resources. The

medical specialties offered within an organization can affect staffing as well as LOS, since not all medical specialties’ diagnoses correlate to DRGs with multiple tiers. For example, if a hospital specializes in labor and delivery, its CDI needs may be less than a hospital that specializes in cardiology. Additionally, medical cardiac patients often have short LOS, whereas oncology patients often have longer LOS and require more follow-up reviews. If
CDIS assignments are made solely by bed count per unit, the work may not be well distributed among team members because of these variations. Also, be aware that the more cross-coverage required across multiple medical specialties, the lower the productivity, as the CDIS will not be as proficient with the disease processes and coding rules associated with all the specialties.
Another consideration is the volume of medical patients compared to surgical patients.
Engaging surgeons in CDI is often more difficult than engaging medical practitioners because of differences in professional billing. Medical providers must provide daily documentation to support their professional billing; therefore, they are often more amenable to respond to queries as well as more likely to add the requested documentation. Surgeons, conversely, are often paid a global fee so they are not required to provide daily documentation for professional billing, and they are often difficult to reach because their days are spent in the operating room.
7.
The payer mix. Initially, most CDI departments focus on Medicare payers. Depending on the payer mix and focus of the CDI department it may be beneficial to include additional payers for review.
Why this affects productivity/staffing:
More CDISs are required to cover additional payers added to the review population. Some organizations perform reviews on all DRG payers, which may exclude reviews on Medicaid or patients covered under commercial insurance; however, many Medicare mandates are also applicable to Medicaid patients (or other payers). As a result it may be beneficial to include the Medicaid or commercial payer population for review if quality measures are a focus, or to reduce vulnerabilities based on government audits/other payer audit results.
8.
Formal/informal education provided to medical staff.
Why this affects productivity/staffing:
Some CDI programs are implemented without providing initial education to the medical staff about the goals and benefits of such a program. It is unrealistic to expect physicians

or other providers to modify their documentation patterns without providing them with the rationale for such expectations.
CDI staffing ratios must take into account that provider education and support is an essential component of successful CDI programs, perhaps the most essential. If education is to be meaningful to providers, it must include research and data analysis, which takes time and effort.
Organizations may choose to enlist the support of outside experts to provide physician education, but it is the day-to-day CDI team that is charged with reinforcing those educational concepts though one-to-one discussions and subject-specific queries. Other hospitals may employ a physician advisor to meet and educate new physician hires as part of the onboarding process.
Each new documentation education concept that is introduced to the medical staff will generally result in an increase in provider queries until documentation patterns improve, thus impacting the productivity of the CDIS. Even though formal education is often only performed by CDI department managers/leadership, the face-to-face education provided by health record reviewers to individual physicians also requires time.
9.
Turnover of CDI staff.
Why this affects productivity/staffing:
The availability of experienced CDISs is inadequate to meet the demands of a growing profession. Major metropolitan areas with multiple hospitals provide competitive opportunities for experienced reviewers, who may choose to advance their career by moving from one organization to another. Hospitals in rural or other areas of the country where experienced CDISs are at a premium may have to reinvest in training expenses should their CDIS decide to leave the organization.
As noted above, it takes time for a new CDIS to become proficient in the CDI role; therefore, it is imperative that facilities take steps to ensure that the expectations and rewards of a CDI program encourage staff retention, especially in those geographic areas that find CDI staffing a challenge.
Unrealistic expectations and inadequate staffing ratios are some of the reasons cited by
CDIS for leaving an organization.
10.
Amount of vacation and sick time.

Why this affects productivity/staffing:
Many organizations staff their CDI programs without regard to providing backup coverage during vacations, sick time, or unexpected absences. Short-term absences of one to three days can generally be covered by remaining team members in a large program; however, CDI programs that consist of only one or two reviewers are severely impacted by the absence of even one CDIS. Vacations or unexpected absences by one CDIS can impact the number of charts reviewed, resulting not only in a productivity decrease but also negatively affecting hospital quality data, CMI, reimbursement, and other outcomes that depend on accurate documentation.
11.
The degree of data entry.
Why this affects productivity/staffing:
Every facility wants data to ensure that its CDI program is “paying dividends” on its investment; therefore, accruing and reporting data is an essential component of most CDI programs. The mechanics of gathering, analyzing, and reporting this data are often timeconsuming and dependent on the systems designed to address these processes.
Facilities should carefully consider the benefits and the burdens of requiring the CDIS to contribute to data acquisition and reporting. The manual abstraction and entry of information into a database or spreadsheet may result in a decrease in the time available to perform chart reviews and/or provider education.
Facilities are encouraged to investigate software programs designed to capture information at the point of review or to assign data entry tasks to administrative personnel, thus freeing the
CDIS to focus his or her time on documentation review and providing education.
12.
Report analysis by CDISs.
Why this affects productivity/staffing:
Reviewing CMI trends, CC/MCC capture rates, and discrepancies in the “working” or concurrent DRG assigned by the CDIS (versus the final DRG assigned by the coding staff) is important and takes time to perform.
13.
Participation on other committees.
Why this affects productivity/staffing:

CDISs or CDI leadership may be asked to serve on committees that address topics such as
Recovery Auditors, PEPPER reports, ICD-10 gap analysis and training, and denials. Meeting preparation, attendance, and follow-up responsibilities may hinder productivity by taking reviewers off the floor.
14.
The physical layout of the hospital.
Why this affects productivity/staffing:
CDISs who are required to spend time on the floors querying physicians face to face will need more time if the floors are large. Multiple floors and back-and-forth travel between floors and the CDIS office space will add to this time.
15.
Paper vs. electronic health records.
Why this affects productivity/staffing:
CDISs who can access charts electronically may be able to review more cases per day by avoiding the need for physical record retrieval. Other veteran CDISs have noted that scrolling through computer screens can take them more time than quickly jumping ahead in a paper health record. Some nurses are not as computer-savvy as others and may require additional time to navigate an electronic record.
16.
Policies on answering/closing out queries.
Why this affects productivity/staffing:
One of the most time-consuming activities for CDISs is interacting with the medical team and seeking clarification through queries. The development of a query consumes a good portion of a CDIS’s day. Some organizations use templates that contain clinical indicators specific to a particular patient to reduce time, while others require each query to be manually tailored to the specific patient. Some organizations require significant follow-up to bring closure to a query, the amount of which varies greatly depending upon physician engagement with CDI and the type of medical record in use at the facility. Other facilities do not require every query to be closed out before final billing. Organizations with hybrid records are finding it increasingly difficult to make queries visible as providers rarely deal with paper charts, but many of these facilities have not yet developed a process for electronic queries.