Clinician's Primer to ICD-10-CM Coding for Cleft Lip/Palate Care

Abstract

On October 1, 2015, the United States required use of the Clinical Modification of the International Classification of Diseases, 10th Revision (ICD-10-CM) for diagnostic coding. This primer was written to assist the cleft care community with understanding and use of ICD-10-CM for diagnostic coding related to cleft lip and/or palate (CL/P).

ICD‐10 impact on ascertainment and accuracy of oral cleft cases as recorded by the Brazilian national live birth information system

“…The deficiencies of the ICD‐10 codes for oral clefts, as well some corrective proposals have been fully discussed in the literature (Allori et al, ; Allori & Cragan, ; Allori, Mulliken, Meara, Shusterman, & Marcus, ; Aylsworth et al, ; McBride et al, ; Taub & Silver, ; Wang et al, ). Essentially, when compared to the previous ICD‐9 system, the ICD‐10 oral cleft codes lack modifiers for severity or clinical subtypes (Allori et al, ), meaning that they lack accuracy and precision to adequately describe oral clefts (Aylsworth et al, ).…”

“…The ICD‐10 classification of oral clefts [Supplementary Figure S1 and Table details in Allori & Cragan, ), substitutes the complete/incomplete specification of ICD‐9 with hard and soft palate specification, and adds a category of uvula bifida, which, however, does not combine with other cleft types. According to the present ICD‐10 developed subcategories, the classifications of unilateral CL and CL without other specifications (NOS: no other specification) are placed together in the same category.…”

Striped-Y redux: Redesigning pictographic notational systems for the digital age

“…Pictograms are prone to under-description due to haste in completion. 6. Pictograms are also prone to misunderstanding.…”

“…th and 10 th clinical modifications (ICD-9-CM and ICD-10-CM), ontologic frameworks such as Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT), and specialized coding extensions such as the British Paediatric Association/Centers for Disease Control and Prevention (BPA/CDC) and the ICD-10-Based Expanded Code Set for Cleft Research and Surveillance were also studied [5][6][7]. These sources were used to identify the level of phenotypic detail that could be expressed via commonly used coding systems, identify the aspects of phenotypic description that were typically lost in encoding, and thereby conceptualize the ideal role that a pictographic notational system would play as an adjunct to existing text-based encoding.…”

ICD‐10–based expanded code set for use in cleft lip/palate research and surveillance

“…Only the ICD‐10‐based expanded code set is able to consistently describe both the severity of the cleft lip and accurate morphology of the cleft palate in satisfactory detail. The CLAP notation utilized to summarize the clinical description is explained in Allori, Mulliken, et al, . The LAHSHAL notational system, while useful, is not shown because of the many thousands of phenotypic descriptions possible with this system.…”