<p>Rapid economic growth resulting from the ascendancy of Saudi Arabia as an international oil producer, and the recognition by the government of the right of all citizens and most expatriate workers to free healthcare facilitated the development of a three-tier health system ranked 26th in the world by the World Health Organisation in 2000. Concurrently, the increasing financial burden of interwoven demographic and socioeconomic factors such as unprecedented population growth, increased life expectancy, and the rise of noncommunicable diseases, necessitated the diversification of health funding in the form of mandatory healthcare insurance. The coding of the clinical documentation of diagnoses and interventions of patient health episodes by clinical coders has become the international standard for submitting health insurance claims and in 2013, a contract was negotiated with the Australian government to adopt the complete ICD-10-AM package.</p><p> A mixed methods approach was selected to determine the factors impacting on the ICD-10-AM implementation in seven public hospitals, which had not previously submitted claims or employed clinical coders. Data were obtained from a quantitative Likert scale questionnaire completed by a random sample of 283 respondents and a qualitative semistructured interview was conducted with seven purposively selected experts while only one physician indicated a desire to be interviewed. Instrument design and content were based on factors drawn from ICD-10 implementation literature representing developed and developing nations. The reviewed Saudi literature covered healthcare management, staffing conditions, inadequate technology and interoperability, and the failure to follow through with previous reform attempts.</p><p> Derived factors were categorised as organisational (planning, staffing, training, and technology); Health information (purpose, benefits, practice, and a knowledge of anatomy, pathology, and interventions); National (implementation support, funding, maintenance, upgrading, and the unified system). SPSS computation of the 5-point Likert scale (1 = strongly agree; 5 = strongly disagree) yielded an overall mean of 4.01 for the 23 items, foreshadowed by a strong negative response to three demographic items querying prior clinical coding certification or ICD-10 training, and implementation status. A 9% minority of highly qualified professionals differed from the majority. Three years after the original implementation date, factors deemed essential, particularly organisational awareness, training, and adequate staff specialists were still being ignored. </p><p> Most respondents had been excluded from job-specific training, showed little understanding of the relevance of ICD-10 and clinical coding in health information management, or a vision of their hospital as a component of a national system. In the only hospital practicing clinical coding it was tasked to the physicians, continuing a Saudi pattern of mediocre reform attempts symptomatic of a fragmented health system lacking leadership.</p>