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



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.



美国卫生和公共服务部长发布了一项最终规则,规定国际疾病,第十修订,临床修改(ICD-10-CM)和国际疾病分类,第十修订,程序编码系统(ICD-100)(ICD-100)(ICD-100)(ICD-100)-pcs)从2013年10月1日开始使用国际疾病分类,第九修改,临床修饰(ICD-9-CM)。1ICD-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.


许多包含与美国ICD-10-CM实施有关的信息的出版物参考了改善临床文档的需求。2, 3然而,到目前为止,没有一个包括信息regarding which diseases and conditions will require improved documentation so that more detailed ICD-10-CM codes can be assigned.


The objective of this exploratory pilot study was to determine whether current levels of clinical documentation provide the detail necessary to fully utilize the ICD-10-CM classification system for heart disease, pneumonia, and diabetes cases.




The first phase of the pilot study required obtaining access to de-identified patient records that could be recoded in ICD-10-CM. Following Institutional Review Board (IRB) review and approval from Texas State University and Texas A&M University, the researchers were able to access a set of records at the Texas A&M Health Science Center Rural and Community Health Institute. They were also granted approval to utilize the de-identified records in the American Health Information Management Association (AHIMA) Virtual Lab database. Two coders were recruited using a combination of ICD-9-CM coding proficiency assessments as well as phone and in-person interviews. The two coders and the researchers were trained to use ICD-10-CM by an AHIMA-certified ICD-10-CM trainer.

编码器和质量保证审稿人使用了2010年版本的ICD-10-CM Codebook和ICD-10-CM编码指南来重述491条记录。在此总数中,从得克萨斯州A&M健康科学中心农村和社区健康研究所数据库中选出了445个记录(90.63%)。从Ahima虚拟实验室数据库中选择了其余46个记录(9.37%)。数据收集工具,一个Excel电子表格,允许进行主诊断,并为每个记录分配29个次要诊断。除了代码外,还记录了每个记录的年龄和性别。

Within the available de-identified record population, the researchers elected to focus on three common and costly healthcare conditions due to study funding limitations. The population of records was reduced to those with a principal diagnosis of heart disease, pneumonia, or diabetes mellitus. The list of ICD-9-CM codes used to select the record population can be found inAppendix A

编码完成后,对编码准确性进行了质量保证过程,以随机选择的10%案例样本进行。质量保证审稿人是CCS认证并参加过先前参考的ICD-10-CM培训的研究人员之一。不准确的代码分配的示例,如Table 1,包括错误分配的有效ICD-10-CM代码,并使用无效的ICD-10- CM代码。编码的总体准确率为95.3%。确定该速率是为了收集数据的目的而接受的。数据分析包括通过使用Microsoft Access数据库的总和条件的描述性统计数据(频率和百分比)的制表。


A total of 491 health records were coded with 4,283 ICD-10-CM codes assigned. Only 935 unique codes were assigned across all of the records. An average of 8.7 codes was assigned per record. One hundred eighty-two records (37 percent) had 10 or more secondary codes. There were 1,180 “unspecified” codes assigned, which accounted for 27.6 percent of the total codes assigned.


Coding for pneumonia cases resulted in frequent assignment of code J18.9 (Pneumonia, unspecified organism). In addition, codes J18.0 (Bronchopneumonia, unspecified organism) and J18.1 (Lobar pneumonia, unspecified organism) were assigned in numerous cases. In these cases, a more specific pneumonia code could not be used since the clinical documentation did not state the causal organism.

Interestingly, the coders assigned very few “unspecified” codes for diabetes mellitus. Diabetes mellitus was rarely used as a principal diagnosis. In a few cases, code E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified) was assigned. In a majority of cases, code E11.9 was assigned for the stated diagnosis of Type 2 diabetes mellitus without complications.

Of the 1,180 “unspecified” codes assigned, some particularly generic codes were assigned.表2lists examples of these code classifications. Codes such as K82.9 (Disease of gallbladder, unspecified) and N19( unspecified kidney failure) were unexpected findings for codes assigned from inpatient acute care records.

两个额外的发现引起了手动coding process used in this study. The first involved numerous validity-type errors that included incorrect assignment of the seventh-character extension, failure to use placeholders, and incomplete ICD-10-CM codes.Table 1lists examples of validity errors found among the codes assigned in this study. The second finding was a an error in coding accuracy in which specific clinical documentation existed but the coder assigned a nonspecific residual category code.



This pilot study had several limitations. First is the small scope of the study and the fact that the researchers felt the need to limit the research to certain conditions. Second, the majority of the records came from an existing database of de-identified records from rural hospitals. Given this source, the conditions and documentation may not be comparable to those found in larger, urban, or academic facilities. Third, the contracted coders were not familiar with the format of the records. In fact, because the records came from a variety of facilities, the coders were working with a variety of formats. Fourth, the funding available was not sufficient to allow coders the use of assistive technologies such as an encoder or even a code editor to check the validity of the codes. Fifth and finally, the study did not include any assessment of interrater reliability between the coders. Therefore, some variation in code assignment could exist that was not measured or controlled.


根据这些发现,使用ICD-10-CM,需要更具体的医师文档来捕获特定类型的心脏病。国家卫生统计中心(NCHS)报告说,美国的主要死亡原因是心脏病。4Some of the potential benefits of ICD-10-CM with increased specificity of documentation regarding heart disease cases include the increased ability to study the relationship of costs and benefits of treatments for specific heart conditions, more accurate payments, a better understanding of health outcomes, and improved quality-of-care measures for heart disease patients.

For instance, with heart failure, the type and severity of heart failure such as acute systolic heart failure or chronic diastolic failure are of great significance. Codes for these conditions already exist in ICD-9-CM, and the fact that they were not used for this study may be more a function of the age and source of the records rather than lack of physician documentation. However, this is not the case for all heart disease conditions. Cardiac arrest codes have been expanded in ICD-10-CM to include codes for cardiac arrest due to an underlying cardiac condition and cardiac arrest due to another underlying condition. ICD-9-CM contains only one code for cardiac arrest. It is reasonable to expect that payers will ultimately require reporting of the additional level of detail related to cardiac arrest. Chronic ischemic heart disease codes also have undergone revision in ICD-10-CM and now include combination codes to capture the site of the atherosclerosis, such as native coronary vessel, as well as the presence of angina pectoris. Physicians will have to document the condition to this level of detail. Lastly, physicians will need to fully describe chest pain. In ICD-10-CM, there is a code to describe ischemic (cardiac-related) chest pain (I20.9), whereas in ICD-9-CM, all codes for chest pain describe unspecified or vague conditions, such as precordial pain.

For the pneumonia cases in this study, the results clearly indicate that more specificity is needed in clinical documentation for classifying bacterial pneumonia because the majority of the cases were coded as pneumonia caused by an unspecified organism. According toCoding Clinic, the American Hospital Association’s official publication of ICD-9-CM coding guidelines, a coder cannot assign a bacterial pneumonia code from a sputum culture.5Only the physician’s documentation of pneumonia and the causative organism will suffice for assigning a more specific bacterial pneumonia code. These coding guidelines for bacterial pneumonia are expected to continue in ICD-10-CM.


与ICD-10-CM中的手动编码有关的结果引起了人们的关注问​​题。没有辅助技术(例如编码器),有效性错误可能会更普遍。ICD-10-CM中疾病编码的新代码结构允许将“ X”用作占位符,并在某些代码类别中使用特定的第七个字符扩展,例如在骨折的肌肉骨骼章节中发现的类别。这项研究的结果表明,在手动编写或将代码键入数据字段时,编码器在编码错误时很容易。另一个问题可能是在ICD-10-CM表格列表中手动搜索代码时,对ICD-9-CM逻辑过高依赖。例如,ICD-9-CM不能为纤维肌痛提供特定的代码,而在ICD-10-CM中,可以提供更多特定的代码。使用ICD-9-CM逻辑的熟练编码器可能会迅速跳到表格列表,并在存在更具体的代码时寻找残差或“未指定”代码。

ICD-10-CMis a robust classification with approximately 50,000 more disease codes than ICD-9-CM. In one sense, coders may feel more comfortable knowing there is a specific code that can accurately classify a disease condition when the supporting clinical documentation exists. Yet this study reflected challenges as well. In a few instances, coders searched for specific codes without success, such as when trying to record dependence on a walker for mobility and daily use of a CPAP device.

此外,程序员可能不同程度的公关oficiency. Coders are trained in many different ways that range from on-the-job training to four-year health information management (HIM) degree programs. Some coders have significant clinical backgrounds, such as having been a registered nurse. In other instances, the coder may have a high school education with minimal knowledge in the biomedical sciences. As a result of their differing education and training, coders will interpret the clinical documentation in different ways, which may lead to inconsistent code assignment. With the implementation of ICD-10-CM on the horizon, coder proficiency should be carefully assessed by healthcare organizations.


Healthcare organizations need to assess clinical documentation and identify gaps. HIM professionals should take a leading role in this work process. HIM professionals working together with clinical documentation improvement teams can devise a customized plan for conducting educational sessions for physicians. These sessions will provide an opportunity to educate physicians on the benefits of a new classification system. These benefits include a better understanding of health outcomes, the ability to analyze the relationship of costs and benefits related to the treatment of specific medical conditions, and the potential for more accurate payments to providers. Organizations should begin analyzing their documentation now and preparing their clinicians regarding necessary changes in clinical documentation.


The results of this pilot study support the many claims that have been made regarding the need for more detailed clinical documentation to support ICD-10-CM coding. Additionally, this study provides organizations with information regarding the adequacy of clinical documentation for heart disease, pneumonia, and diabetes. Finally, this study provides an outline for organizations to follow should they wish to focus on improvement of clinical documentation and ICD-10-CM coding for their own priority conditions.

Jackie Moczygemba, MBA, RHIA, CCS, is an associate professor of health information management at Texas State University in San Marcos, TX.

Susan H. Fenton, PhD, RHIA, is an assistant professor of health information management at Texas State University in San Marcos, TX.


1.卫生与公共服务部。“ HIPAA管理简化:对医学数据代码设置标准的修改,以采用ICD-10-CM和ICD-10-PCS。”45 CFR第162部分。Federal Register74, no. 11 (January 16, 2009): 3328–62. Available athttp://edocket.access.gpo.gov/2009/pdf/e9-743.pdf(accessed September 21, 2009).
2. Bowman, S., and R. Butler. ICD-10 Update.2008 AHIMA Convention Proceedings。华盛顿州西雅图:阿希马,2008年。
3. Ingenix。为ICD-10做准备:评估方法和潜在的陷阱。伊甸草原,明尼苏达州,2008年,第1-6页。可用http://www.icd10prepared.com
4. Xu, J., K. Kochanek, S. Murphy, and B. Tejada-Vera. “Deaths: Final Data for 2007.”National Vital Statistics Reports58, no. 19 (2010): 135.
5.美国医院协会。Coding Clinic(Second Quarter 1998): 4.

Jackie Moczygemba,MBA,Rhia,CCS;和Susan H. Fenton博士,Rhia。“从ICD-10-CM临床文档试点研究中学到的教训”健康信息管理的观点(2012年冬季):1-11。

Printer friendly version of this article

Posted in:

Leave a Reply