WHO-FIC APN field trial shows that a simplified version of ICD-10 is feasible in developing countries

October 22, 2018

Findings from a field trial recently published in Health Information Management Journal show that a simplified version of ICD-10-CM may be an effective tool in developing countries that have been unable to collect ICD-10-based health statistics.

In many developing countries, the number of clinical coders is insufficient to complete clinical coding work. Underbudgeting and a lack of employment opportunities for medical coders has forced hospital systems to shift work designated for medical coders to professionals in other specialties. 

To promote ICD-10 implementation in the Asia-Pacific region, the World Health Organization Family of International Classifications Asia-Pacific Network (WHO-FIC APN) developed a simplified version of ICD-10-CM and tested it in Cambodia during February and March 2016.

The simplified version includes common diagnostic statements as index terms. For example, coders can locate the ICD-10 code for “acute appendicitis” by looking up the word “acute” rather than the lead term “appendicitis.”

In addition, the diagnostic index lists all ICD-10 codes by patient type to reduce confusion for any untrained users of the index. Patient types are defined as:

  • General: pediatric patients over 28 days of age or an adult who is not pregnancy, in the delivery episode, or in the postpartum period

  • Congenital: a patient with a disease classified as congenital

  • Perinatal: pediatric patient under 29 days of age

  • Pregnancy: a patient who is currently pregnant

  • Childbirth: a patient who has just given birth and is in the delivery episode of care

  • Postpartum: a patient who is in the postpartum or puerperal period

The restructured index enables coders to select ICD-10 diagnosis codes by following four simple steps:

  1. Identify the type of statement to be coded and refer to the appropriate section of the manual (i.e. if the statement is a disease, injury, or other condition classifiable to chapter 1-19 or 21, see section I)

  2. Locate the main diagnosis term

  3. Select the appropriate diagnosis code based on patient context (i.e. patient type)

  4. Assign the code

To test the usability of the simplified system, in 2016 ten hospitals were randomly selected by the Cambodian Ministry of Health for inclusion in the study. Each hospital was asked to identify 100 cases documented within three months prior to the field trial and within the following categories:

  • Other diagnoses (40 cases)

  • Infections (15 cases)

  • Injuries (15 cases)

  • Tumors or cancers (10 cases)

  • Postpartum cases (5 cases)

  • Perinatal cases (5 cases)

Each hospital sent a team of one physician and one potential clinical coder with little to no experience using ICD-10-CM to a training workshop for the simplified system prior to participation in the field test. Upon completion of training and over the course of six weeks, participants were asked to assign ICD-10-CM codes using the Asia-Pacific Network ICD-10 simplified version, for cases selected by their hospital.

Researchers found that the average accuracy rate for all cases was approximately 81%. Coding errors were attributed to either the coder, the physician, or the coding system. The most common coding errors for both coders and physicians were for cases involving neoplasms and congenital diseases.

Unlike the full ICD-10-CM Manual, the simplified version does not include four-digit external cause codes and lacks dagger and asterisk conventions to identify the etiology and manifestation for certain conditions. The simplified manual is not intended to replace the current ICD-10-CM Manual but may be used as an introductory tool to pave the way for implementation of the full ICD-10 or ICD-11 Manual in developing countries.

Target countries for potential implementation of the simplified version are Myanmar, Lao, Cambodia, Vietnam, Mongolia, the Philippines, Indonesia, Bhutan, Timor-Leste, Nepal, and Papua New Guinea.