Improving ICD Coding in the Emergency Department: Factors Related to Use of "Unspecified" Codes for Head and Brain Injury.

CONTEXT

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.

OBJECTIVES

This process evaluation sought to understand medical ICD-10-CM coding behaviors for TBI in emergency department (ED) settings.

DESIGN

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.

SETTING

Video interviews were conducted with a nationwide sample in the United States.

PARTICIPANTS

A purposive snowball sampling strategy was used to recruit 26 ED physicians with experience diagnosing TBI.

INTERVENTION

Semi-structured interviews identified factors related to the selection of specific ICD codes for head injury.

MAIN OUTCOME MEASURE

Thematic analysis of transcribed data.

RESULTS

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.

CONCLUSIONS

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.