A Transformative Innovation to Clinical Coding for Better Data and Less Burden

Abstract

Background: The importance of codes for documenting healthcare concepts has expanded from a historical need to collect statistics to today's wide array of clinical and other secondary uses. The most deeply embedded system for coding diagnoses is the World Health Organization's (WHO) International Classification of Diseases (ICD). WHO's eleventh revision, ICD-11, was evaluated to determine how best to meet the needs of stakeholders concerned about clinical quality, healthcare decision-making, and other secondary use cases.

Methods: This study explored the capability of ICD-10-CM, the standard ICD-11 for Mortality and Morbidity Statistics (ICD-11-MMS), and an enhanced ICD-11-MMS prototype (ICD-11-CCL) to represent clinical patient profiles for two natural clinical language scenarios. Systems were evaluated for granularity, comprehensiveness, accuracy, precision, relevancy, and their capability to provide user-friendly coding support.

Results: Both the standard and enhanced ICD-11-MMS produced code clusters that captured more clinical details and insight than ICD-10-CM's codes. However, ICD-11-MMS was less comprehensive than ICD-11-CCL and introduced occasional new inaccuracies. Unlike ICD-10-CM and ICD-11-MMS, ICD-11-CCL enabled clinicians to designate their clinical perspectives directly. While ICD-11-MMS produced numerous synonymous code clusters, the enhanced syntax of ICD-11-CCL resulted in a unique code cluster for each scenario.

Conclusions: Adoption of an enhanced ICD-11-MMS such as ICD-11-CCL could provide clinically nuanced data to support important secondary data applications more effectively than standard ICD-11-MMS, while retaining ICD-11-MMS's capability to support international comparative analyses such as mortality and morbidity statistics. With automated coding tools, enhanced ICD-11-MMS could also reduce the burden on humans to select, review, memorize or decipher codes. Enhanced ICD-11-MMS represents a substantial improvement over customized modifications of ICD-10 and, with further development and testing, could be a viable option for future adoption.

Keywords: Clinical Coding; Clinical Decision-Making; International Classification of Diseases; Knowledge Bases; Morbidity; Mortality; Semantics.

Figure 1.. Evolution of Patient Health Status and Appropriateness of Clinical Interventional Responses As Evaluated Based on Actual Health Status, on ICD-10-CM Reported Health Status, and on ICD-11-CCL Reported Health Status

First, the actual evolution of the patient’s health status is illustrated both for acute and for chronic conditions, shown left to right on a horizontal axis of time. The occurrence of acute conditions is illustrated by gray rectangles that become darker as severity increases and black when the patient dies. The progressively increasing burden of chronic diseases is illustrated below in a similar manner. Diamonds indicate 14 clinical interventions based on the accurate assessments of acute and chronic conditions, designated by arrows. Next, the evolution of the same patient’s health status based on ICD-10-CM codes is illustrated in the middle section below the actual status. Loss of clinical nuance is consistent with prior and current empirical findings. In this illustration, seven of the 14 appropriate interventions would no longer be considered appropriate (marked by X). For example, the chronologically first intervention appears to be too intensive because the ICD-10-CM code for an acute condition suggested greater than actual severity (darker shaded box), and the sixth chronological service appears to be inappropriate because ICD-10-CM coding missed the progression of severity in a chronic condition. Finally, the evolution of the same patient’s health status is illustrated based on ICD-11-CCL clusters. Loss of clinical nuance again is consistent with prior and current empirical findings. In this illustration, only one of the 14 appropriate interventions would no longer be considered appropriate. As above for ICD-10-CM, the sixth chronological service appears to be inappropriate because, in this illustration, ICD-11-CCL coding still missed the progression of severity in one chronic condition.