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Lessons learned from an ICD-10-CM clinical documentation pilot study
Jackie Moczygemba1, Susan H Fenton
1Texas State University in San Marcos, TX, USA.
Perspectives in Health Information Management
|May 2, 2012
Summary
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) requires detailed clinical documentation. Healthcare organizations must assess documentation and coder proficiency before ICD-10-CM implementation for accurate diagnosis coding.
Area of Science:
- Health Informatics
- Medical Coding Systems
- Clinical Documentation Improvement
Background:
- The United States is transitioning from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) by October 1, 2013.
- ICD-10-CM is mandated for recording diagnoses and reasons for care within the healthcare system.
- The enhanced detail in ICD-10-CM necessitates a thorough review of current clinical documentation practices.
Purpose of the Study:
- To evaluate the adequacy of existing inpatient clinical documentation for comprehensive ICD-10-CM coding.
- To identify potential challenges in utilizing the ICD-10-CM classification system for common conditions like heart disease, pneumonia, and diabetes.
- To inform healthcare organizations about necessary preparations for ICD-10-CM implementation.
Main Methods:
- A cross-sectional pilot study design was employed.
- Four hundred ninety-one de-identified inpatient medical records were analyzed.
- Records were coded using established ICD-10-CM guidelines and official codebooks.
Main Results:
- The study identified significant gaps in the level of detail within current inpatient clinical documentation.
- Findings suggest that existing documentation may not fully support the specificity required by ICD-10-CM.
- Variability in coder proficiency necessitates assessment and targeted training.
Conclusions:
- Healthcare organizations must proactively assess clinical documentation for completeness and accuracy.
- Evaluating coder proficiency is crucial to identify training needs in both biomedical sciences and the ICD-10-CM system.
- Preparation is essential for successful and compliant ICD-10-CM adoption.
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