Top documentation challenges in the ICD-10 transition

Improving the 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," says  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 says. And she lists 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 renal failure in so many different ways."

• Respitory 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.