Top documentation challenges in the ICD-10 transition


Improving clinical documentation will be a requirement of the ICD-10 transition. Does it really need to start now?

"Once physicians learn to document, you won't need [clinical documentation specialists] anymore," said Melinda Tully, MSN, CCDS, CDIP, vice president of Clinical Services & Education, J.A. Thomas & Associates, a Nuance company. "That position has the biggest job security in the world."

There are plenty of diagnoses that can be better documented now, she explained. And she listed five diagnoses that give documentation specialists the most problems:

  • Heart failure is "the bane of existence for every documentation specialist."
  • Pneumonia is a high-volume opportunity for documentation queries.
  • Renal failure is a problem "because you can document it in so many different ways."
  • Respiratory failure has the same issue as renal failure.
  • Acute hypovolemia very often is under-reported. "I have been doing this for 14 years, and you still have to ask surgeons that have just repaired a big femur fracture if you have to give them three or four units of blood if the patient had acute hypovolemia."

Documenting any of these isn't going to get easier in the ICD-10 transition.

Carl Natale blogs regularly at ICD10Watch.com.