title: Lessons learned from an ICD-10-CM clinical documentation pilot study.
abstract: 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.
authors.affiliation: Texas State University in San Marcos, TX, USA.
authors.forename: Jackie
authors.initials: J
authors.lastname: Moczygemba
authors.forename: Susan H
authors.initials: SH
authors.lastname: Fenton
mesh_terms: D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000145:classification; D004282:Documentation / Q000592:standards; D006331:Heart Diseases / Q000145:classification; D006801:Humans; D038801:International Classification of Diseases / Q000145:classification* / Q000639:trends; D010865:Pilot Projects; D011014:Pneumonia / Q000145:classification; D011785:Quality Assurance, Health Care