Problems and barriers in the transition to ICD-10-CM/PCS: A qualitative study of medical coders’ perceptions

Abstract

Background. Clinical coding is the process of transforming the information about diseases or procedures recorded in the health records, into numeric or alphanumeric codes, using an international classification system. Recently, a new version of the classification system (ICD-10-CM/PCS) started being used in Portugal. Objective. To explore the perceptions of medical coders (medical doctors) regarding problems related to the transition from ICD-9-CM to ICD-10-CM/PCS that may affect the quality of coded data. Methods. A qualitative study using four focus groups sessions with ten medical coders was performed between October and November 2017. The convenience sample was obtained from four public hospitals in Portugal. Questions related to problems with the coding process were developed by reviewing literature and with authors’ expertise. The focus groups sessions were taped, transcribed and analyzed to elicit themes. Results. Several problems related to the classification system transition were identified by the medical coders: more time spent in coding, decreased productivity, lack of clinical coding audits and lack of consensus and guidelines. Conclusion. The availability of more tools to help medical coders, the establishment of guidelines and consensus, and clinical coding audits could increase the quality of coded data, contributing to achieve the expected improvements with the introduction of ICD-10-CM/PCS, namely in the purposes it is collected for.