Introduction In 2016, a proposed International Classification of Diseases, Tenth Edition, Clinical Modification surveillance definition for traumatic brain injury (TBI) morbidity was introduced that excluded the unspecified injury of head (S09.90) diagnosis code. This study assessed emergency department (ED) medical records containing S09.90 for evidence of TBI based on medical documentation. Methods State health department representatives in Maryland, Kentucky, Colorado and Massachusetts reviewed a target of 385 randomly sampled ED records uniquely assigned the S09.90 diagnosis code (without proposed TBI codes), which were initial medical encounters among state residents discharged home during October 2015–December 2018. Using standardised abstraction procedures, reviewers recorded signs and symptoms of TBI, and head imaging results. A tiered case confirmation strategy was applied that assigned a level of certainty (high, medium, low, none) to each record based on the number and type of symptoms and imaging results present in the record. Positive predictive value (PPV) of S09.90 by level of TBI certainty was calculated by state. Results Wide variation in PPV of sampled ED records assigned S09.90: 36%–52% had medium or high evidence of TBI, while 48%–64% contained low or no evidence of a TBI. Loss of consciousness was mentioned in 8%–24% of sampled medical records. Discussion Exclusion of the S09.90 code in surveillance estimates may result in many missed TBI cases; inclusion may result in counting many false positives. Further, missed TBI cases influenced by incidence estimates, based on the TBI surveillance definition, may lead to inadequate allocation of public health resources.

中文翻译：

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ICD-10-CM 编码转换后因不明原因头部损伤急诊就诊的多站点病历审查

引言 2016 年，引入了拟议的国际疾病分类第十版，外伤性脑损伤 (TBI) 发病率的临床修改监测定义，其中排除了未指定的头部损伤 (S09.90) 诊断代码。本研究根据医疗文件评估了急诊科 (ED) 医疗记录，其中包含 S09.90 的 TBI 证据。方法 马里兰州、肯塔基州、科罗拉多州和马萨诸塞州的州卫生部门代表审查了 385 份随机抽样的 ED 记录的目标，这些记录被唯一分配了 S09.90 诊断代码（没有提议的 TBI 代码），这些记录是 2015 年 10 月出院回家的州居民的初次医疗遭遇– 2018 年 12 月。使用标准化的抽象程序，审查员记录了 TBI 的体征和症状，以及头部成像结果。应用分层病例确认策略，根据记录中出现的症状和成像结果的数量和类型，为每个记录分配一个确定性级别（高、中、低、无）。S09.90 的 TBI 确定性水平的阳性预测值 (PPV) 由州计算。结果 指定为 S09.90 的抽样 ED 记录的 PPV 差异很大：36%–52% 具有中度或高度 TBI 证据，而 48%–64% 包含低度或无 TBI 证据。8%–24% 的抽样医疗记录中提到了意识丧失。讨论 在监测估计中排除 S09.90 代码可能会导致许多 TBI 病例漏诊；包含可能会导致计算许多误报。此外，根据 TBI 监测定义，受发病率估计影响的漏诊 TBI 病例，