Integration of Postcoordination Content into a Clinical Interface Terminology to Support Administrative Coding.

Area of Science:

• Health Informatics
• Medical Terminology
• Clinical Documentation

Background:

• Clinical interface terminologies (CITs) are essential for clinical documentation and secondary data use.
• Accurate mapping to administrative coding systems like ICD-10-CM is crucial for healthcare billing.
• The transition to ICD-10-CM increased documentation complexity.

Purpose of the Study:

• To develop a CIT content layer that facilitates accurate ICD-10-CM coding.
• To provide postcoordination prompts for capturing necessary diagnostic details.
• To ensure mapped terms reflect user-added details in secondary vocabularies.

Main Methods:

• Developed a CIT content layer with postcoordination prompts for ICD-10-CM details.
• Integrated the system with clinical information systems and refined with end-users.
• Addressed ICD-10-CM irregularities with specific postcoordination measures.

Main Results:

• Implemented a system used by approximately 30,000 healthcare organizations.
• Content covers the majority of encounter diagnoses, with largely positive user feedback.
• Addressed ICD-10-CM coding challenges through postcoordination.

Conclusions:

• Demonstrated the first system using postcoordination to capture ICD-10-CM details in CITs.
• The system maps user-added details to other vocabularies, enhancing data utility.
• Successfully improved clinical documentation for secondary data uses.