Lessons learned from an ICD-10-CM clinical documentation pilot study

• Published in: Perspectives in health information management Vol. 9; no. Winter; p. 1c
• Main Authors: Moczygemba, Jackie, Fenton, Susan H
• Format: Journal Article
• Language: English
• Published: United States American Health Information Management Association 2012
• Subjects: Cross-Sectional Studies; Diabetes Mellitus - classification; Documentation - standards; Heart Diseases - classification; Humans; International Classification of Diseases - classification; International Classification of Diseases - trends; Pilot Projects; Pneumonia - classification; Quality Assurance, Health Care; coding proficiency; ICD-10-CM; biomedical sciences; clinical documentation; clinical documentation improvement teams
• ISSN: 1559-4122; 1559-4122

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.