Allori Alexander C, Cragan Janet D, Cassell Cynthia H, Marcus Jeffrey R
Division of Plastic, Maxillofacial & Oral Surgery; Duke University Hospital & Children's Health Center; Durham, North Carolina, USA.
National Center on Birth Defects and Developmental Disabilities (NCBDDD), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA.
Birth Defects Res A Clin Mol Teratol. 2016 Nov;106(11):905-914. doi: 10.1002/bdra.23544.
On October 1, 2015, the United States required use of the Clinical Modification of the International Classification of Diseases, 10 Revision (ICD-10-CM) for diagnostic coding. The ICD-10-CM code set is limited to gross categories for cleft lip and/or cleft palate (using only four of a possible seven characters).
Herein, a clinically useful expansion of the ICD-10-CM code set is proposed to improve the diagnostic accuracy necessary for individual clinical, research, and statistical projects that require it. (This is similar to how the Centers for Disease Control and Prevention/British Paediatric Association Code served to extend the ICD-9 code base.) RESULTS: Our proposed expansion does not replace the required use of ICD-10-CM for clinical, administrative, or financial transactions. Rather, it is offered as an optional set of cleft codes that could be used in parallel to document true classification-level data with phenotypic accuracy.
The expanded set is "collapsible" into the official ICD-10-CM codes; this improves compatibility of the expanded codes that would be contained in research and epidemiologic databases with the standard codes from hospital electronic medical record systems and administrative billing data. Birth Defects Research (Part A) 106:905-914, 2016. © 2016 Wiley Periodicals, Inc.
2015年10月1日，美国要求使用《国际疾病分类第十次修订本临床修订版》（ICD - 10 - CM）进行诊断编码。ICD - 10 - CM编码集仅限于唇裂和/或腭裂的总体类别（仅使用可能的七个字符中的四个）。
在此，我们提议对ICD - 10 - CM编码集进行临床实用的扩展，以提高个体临床、研究及需要此编码的统计项目所需的诊断准确性。（这类似于疾病控制和预防中心/英国儿科学会编码用于扩展ICD - 9编码库的方式。）结果：我们提议的扩展并不取代在临床、行政或财务交易中对ICD - 10 - CM的要求使用。相反，它作为一组可选的腭裂编码提供，可并行使用以准确记录具有表型的真实分类级别数据。
扩展集可“合并”为官方的ICD - 10 - CM编码；这提高了研究和流行病学数据库中包含的扩展编码与医院电子病历系统的标准编码及行政计费数据的兼容性。《出生缺陷研究（A部分）》106:905 - 914，2016年。© 2016威利期刊公司。
