{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,30]],"date-time":"2026-04-30T05:42:11Z","timestamp":1777527731255,"version":"3.51.4"},"reference-count":24,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"1","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2025,1]]},"abstract":"<jats:sec>\n            <jats:title>Context<\/jats:title>\n            <jats:p>In the emergency department (ED) setting, prioritizing triage and patient care may lead to challenges in capturing detailed documentation necessary for specific International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding in medical records. Consequently, the prevalent use of the \u201cunspecified head injury\u201d code poses concerns about the precision of ED-based administrative billing claims data when analyzed for public health surveillance of nonfatal traumatic brain injuries (TBIs). Understanding the perspective of medical coders can illuminate coding processes and opportunities to enhance coding accuracy for TBI and other head injuries in the ED.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Objective<\/jats:title>\n            <jats:p>This evaluation explores medical coders\u2019 perspectives and challenges when assigning ICD-10-CM codes to head injuries in the ED.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Design<\/jats:title>\n            <jats:p>This qualitative evaluation utilized a phenomenological approach, which employed semi-structured interviews to understand medical coders\u2019 perspectives, processes, and coding determinations for head injuries in the ED.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Setting<\/jats:title>\n            <jats:p>Interviews were conducted using a HIPAA-compliant video-based platform between July 2022 and January 2023.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Participants<\/jats:title>\n            <jats:p>Seventeen medical coders with ED coding experience were interviewed. Their backgrounds were diverse, though most had more than 15\u00a0years of experience.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Main Outcomes<\/jats:title>\n            <jats:p>Four qualitative themes emerged, which highlighted challenges with lack of detailed documentation, defaulting to unspecified codes, time, and productivity pressure, and additional insights into coders\u2019 assumptions and code determination processes.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>Medical coders expressed challenges assigning ICD-10-CM codes to the highest level of specificity, citing issues including insufficient documentation by ED providers and terminology variations. Workplace time constraints and pressure for expedited claims also led to defaulting to unspecified codes.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions<\/jats:title>\n            <jats:p>This evaluation highlights the need for improved documentation consistency and detail in ED records to facilitate accurate ICD-10-CM coding. Alleviating time pressures, improving algorithms, and offering specialized training opportunities to medical coders could be helpful steps to improve coding specificity and data accuracy for head injuries in the ED.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1097\/phh.0000000000002003","type":"journal-article","created":{"date-parts":[[2024,8,9]],"date-time":"2024-08-09T20:54:19Z","timestamp":1723236859000},"page":"99-106","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":4,"title":["Medical Coders\u2019 Use of the ICD-10-CM \u201cUnspecified\u201d Codes for Head and Brain Injury in Emergency Department Settings"],"prefix":"10.1097","volume":"31","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3734-8380","authenticated-orcid":false,"given":"Tracy","family":"Wharton","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Morgan","family":"Bailey","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexis","family":"Peterson","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kelly","family":"Sarmiento","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julia A.","family":"Bleser","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emily Hunt","family":"Costello","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"276","published-online":{"date-parts":[[2024,11,10]]},"reference":[{"issue":"69","key":"R2-20250114","doi-asserted-by":"crossref","first-page":"101296","DOI":"10.1016\/j.ienj.2023.101296","article-title":"Missed nursing care in emergency departments: a scoping review","author":"Duhalde","year":"2023","journal-title":"Int Emerg Nurs"},{"key":"R3-20250114","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1016\/j.ajem.2022.10.009","article-title":"Comparison of clinical note quality between an automated digital intake tool and the standard note in the emergency department","volume":"63","author":"Eshel","year":"2023","journal-title":"Am J Emerg Med"},{"issue":"S1","key":"R4-20250114","doi-asserted-by":"crossref","first-page":"i13","DOI":"10.1136\/injuryprev-2019-043517","article-title":"Multisite medical record review of emergency department visits for unspecified injury of head following the ICD-10-CM coding transition","volume":"27","author":"Peterson","year":"2021","journal-title":"Inj Prev"},{"issue":"1","key":"R5-20250114","first-page":"31","article-title":"Accuracy of mild traumatic brain injury case ascertainment using ICD-9 codes","volume":"13","author":"Bazarian","year":"2006","journal-title":"Acad Emerg Med"},{"issue":"6","key":"R7-20250114","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1093\/intqhc\/mzm042","article-title":"Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups","volume":"19","author":"Tong","year":"2007","journal-title":"Int J Qual Health Care"},{"key":"R8-20250114","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1136\/bmjqs-2015-004411","article-title":"SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process","volume":"25","author":"Ogrinc","year":"2016","journal-title":"BMJ Qual Saf"},{"issue":"1","key":"R9-20250114","doi-asserted-by":"crossref","first-page":"160940691771213","DOI":"10.1177\/1609406917712131","article-title":"Rapid and rigorous qualitative data analysis","volume":"16","author":"Watkins","year":"2017","journal-title":"Int J Qual Methods"},{"issue":"4","key":"R10-20250114","doi-asserted-by":"crossref","first-page":"1893","DOI":"10.1007\/s11135-017-0574-8","article-title":"Saturation in qualitative research: exploring its conceptualization and operationalization","volume":"52","author":"Saunders","year":"2018","journal-title":"Qual Quant"},{"issue":"1","key":"R11-20250114","first-page":"28","article-title":"Health records as the basis of clinical coding: is the quality adequate? 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