Perspect Health Inf Manag - Lessons learned from an ICD-10-CM clinical documentation pilot study.

Tópicos

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Resumo

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.

Resumo Limpo

octob intern classif diseas tenth revis clinic modif icdcm will mandat use unit state place intern classif diseas ninth revis clinic modif icdcm new classif system will use throughout nation healthcar system record diagnos reason treatment care pilot studi conduct determin whether current level inpati clinic document provid detail necessari fulli util icdcm classif system heart diseas pneumonia diabet case design pilot studi crosssect four hundr ninetyon deidentifi record two sourc code use icdcm guidelin codebook find studi indic healthcar organ need assess clinic document identifi gap addit coder profici assess prior icdcm implement determin need educ train biomed scienc along train new classif system

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