Table 2:

Overview of qualitative themes and sub-codes

Theme	Sub-codes
Participant experience and training as factors in documentation	Background and training Experience and expertise
Factors related to assigning an ICD-10-CM code	Prioritizing patient care • Needing additional information, challenges of diagnosis • Unclear or minor injury and polytrauma contexts Time pressure and competing priorities related to the electronic medical record (EMR) • Finding the right code- pull down menus, prompts, volume of options, terminology and key words • Multiple people entering data in the EMR Impacts of specific diagnosis in emergency department • Appropriateness of vague codes for context reasons related to limited observation, liability concerns, or potential for unintended impacts
Medical coders and billing	Unclear connections for providers between coding and billing
Opportunities for action	Increasing access to education and training Resource needs • Clinical decision support making tools and calculators • Hyperlinks and icons Potential facilitators for improvements • Streamlined EMR codes • Feedback from providers at the design and formatting stages of EMR updates • Timely and brief evidence updates related to changes in guidelines for appropriate TBI diagnostics and ICD-10-CM coding