Multisite medical record review of emergency department visits for unspecified injury of head following the ICD-10-CM coding transition.

摘要: Introduction In 2016, a proposed International Classification of Diseases, Tenth Edition, Clinical Modification surveillance definition for traumatic brain injury (TBI) morbidity was introduced that excluded the unspecified head (S09.90) diagnosis code. This study assessed emergency department (ED) medical records containing S09.90 evidence TBI based on documentation. Methods State health representatives in Maryland, Kentucky, Colorado and Massachusetts reviewed target 385 randomly sampled ED uniquely assigned code (without codes), which were initial encounters among state residents discharged home during October 2015–December 2018. Using standardised abstraction procedures, reviewers recorded signs symptoms TBI, imaging results. A tiered case confirmation strategy applied level certainty (high, medium, low, none) to each record number type results present record. Positive predictive value (PPV) by calculated state. Results Wide variation PPV S09.90: 36%–52% had medium or high while 48%–64% contained low no TBI. Loss consciousness mentioned 8%–24% records. Discussion Exclusion estimates may result many missed cases; inclusion counting false positives. Further, cases influenced incidence estimates, definition, lead inadequate allocation public resources.