Lessons Learned from an ICD-10-CM Clinical Documentation Pilot Study

摘要

On October 1, 2013, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) will be mandated for use in the United States in place of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). This new classification system will used throughout the nation's healthcare system for recording diagnoses or the reasons for treatment or care. A pilot study was conducted to determine whether current levels of inpatient clinical documentation provide the detail necessary to fully utilize the ICD-10-CM classification system for heart disease, pneumonia, and diabetes cases. The design of this pilot study was cross-sectional. Four hundred ninety-one de-identified records from two sources were coded using ICD-10-CM guidelines and codebooks. The findings of this study indicate that healthcare organizations need to assess clinical documentation and identify gaps. In addition, coder proficiency should be assessed prior to ICD-10-CM implementation to determine the need for further education and training in the biomedical sciences, along with training in the new classification system.The US Secretary of Health and Human Services has issued a final rule mandating that the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) be used in place of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) beginning on October 1, 2013.~(1) ICD-9-CM is currently used throughout the nation's healthcare system for recording diagnoses or the reasons for treatment or care. It is also used to measure the quality, safety, and effectiveness of care; design payment systems; process claims for reimbursement; conduct research, epidemiological studies, and clinical trials; and set health policy.