Wharton Tracy, Costello Emily Hunt, Peterson Alexis, Bleser Julia A, Sarmiento Kelly, Bailey Morgan
National Network of Public Health Institutes, Washington, District of Columbia (Dr Wharton and Mss Costello, Bleser, and Bailey); and Centers for Disease Control and Prevention, Division of Injury Prevention, Atlanta, Georgia (Dr Peterson and Ms Sarmiento).
J Public Health Manag Pract. 2025;31(1):107-115. doi: 10.1097/PHH.0000000000002012. Epub 2024 Sep 24.
International Classification of Diseases (ICD) codes are used for billing but also for surveillance for injuries such as traumatic brain injuries (TBI). While specificity is possible in the ICD-10-CM scheme, use of the code for unspecified injury of head (SO9.9) remains high.
This process evaluation sought to understand medical ICD-10-CM coding behaviors for TBI in emergency department (ED) settings.
Semi-structured interviews explored the processes that facilitate or hinder ED physicians from selecting specific ICD codes for TBI and potential points of intervention for increased coding specificity and reducing the use of unspecified codes.
Video interviews were conducted with a nationwide sample in the United States.
A purposive snowball sampling strategy was used to recruit 26 ED physicians with experience diagnosing TBI.
Semi-structured interviews identified factors related to the selection of specific ICD codes for head injury.
Thematic analysis of transcribed data.
Four main themes emerged from the data: the impact of training and expertise, factors related to diagnosis, unclear connections with medical coders, and actionable recommendations. Interviews underscored the context surrounding "unspecified" codes for TBI, including demands from patient care, time pressures, issues around how a diagnosis may impact patient management decisions, and considerations related to mapping within the electronic medical record (EMR) where options may default to an unspecified code.
Findings from this analysis indicate that ED providers may benefit from more robust training on how documentation can better support ICD-10-CM coding for this type of trauma. Revised EMR structures could support efficient coding specificity and clarity.
国际疾病分类（ICD）编码用于计费，也用于诸如创伤性脑损伤（TBI）等损伤的监测。虽然在ICD - 10 - CM方案中可以实现特异性，但头部未指定损伤代码（SO9.9）的使用仍然很高。
本过程评估旨在了解急诊科（ED）环境中TBI的医学ICD - 10 - CM编码行为。
半结构化访谈探讨了促进或阻碍急诊科医生为TBI选择特定ICD代码的过程，以及提高编码特异性和减少未指定代码使用的潜在干预点。
在美国对全国范围内的样本进行了视频访谈。
采用目的抽样滚雪球策略招募了26名有诊断TBI经验的急诊科医生。
半结构化访谈确定了与头部损伤特定ICD代码选择相关的因素。
对转录数据进行主题分析。
数据中出现了四个主要主题：培训和专业知识的影响、与诊断相关的因素、与医学编码员的联系不明确以及可采取行动的建议。访谈强调了TBI“未指定”代码周围的背景，包括患者护理的需求、时间压力、诊断如何影响患者管理决策的问题，以及与电子病历（EMR）中映射相关的考虑因素，在电子病历中选项可能默认为未指定代码。
该分析结果表明，急诊科提供者可能会从关于文档如何更好地支持此类创伤的ICD - 10 - CM编码的更有力培训中受益。修订后的电子病历结构可以支持高效的编码特异性和清晰度。
