查詢結果分析
來源資料
頁籤選單縮合
題 名 | 醫師與疾病分類員編碼差異探討--以某醫學中心呼吸系統主診斷為例=The Differences between Doctor and Coder in ICD-9-CM Coding--Example for Respiratory System Cases in a Medical Center |
---|---|
作 者 | 林玲珠; 陳星助; 林坤慧; 張蘋蘋; | 書刊名 | 病歷管理期刊 |
卷 期 | 6:1 民95.11 |
頁 次 | 頁58-71 |
分類號 | 419.26 |
關鍵詞 | 疾病分類代碼; 主診斷; 一致率; ICD-9-CM; Principle diagnosis; Coding quality; |
語 文 | 中文(Chinese) |
中文摘要 | 診斷關聯群(Diagnosis Related Group,DRGs)支付制度下疾病分類代碼(ICD-9-CM)直接反應醫療費用的支付,因此醫院對於代碼的品質及申報的時效更加重視。醫院申報的疾病分類代碼主要來自醫師及疾病分類員,二者皆採用ICD-9-CM 2001年版的工具書,然而依據文獻,醫師及疾病分類員所提供的代碼互有差異,故國內外醫院所申報的ICD-9-CM碼,仍須透過疾病分類員重新編碼後申報。本研究以某醫學中心因呼吸系統疾病而入院的個案為對象,分析其疾病代碼資料,並邀請已從事疾病分類實務工作超過7年以上資深分類員,依實際案例進行差異原因分析。研究資料包含小兒科及胸腔內科半年之住院資料804筆,比對醫師記錄於出院病歷摘要(Discharge Summary)的疾病主診斷代碼與經疾病分類編碼後代碼,分析二者主診斷代碼之一致率。結果發現小兒科及胸腔內科平均一致率分別達59.21%及 32.71%與國外平均一致率平均達95%以上,相差甚遠。為能瞭解代碼不一致率原因,經病歷查閱及專家分析結果歸納為:1.醫師未使用合併碼或最細碼;2.醫師後續提供之診斷以手寫補入但未鍵入資料庫;3.病歷書寫內容不一致;4.多重主診斷未依權重高低選取等。此分析結果更加突顯疾病分類員之專業性,醫院若期望病患出院前即有正確且完整的診斷,則須修改醫囑程式或作業流程並對醫師進行編碼原則之教育訓練,以減少院內代碼不一致之情形,以期未來 DRGs支付制度下申報正確又即時之疾病代碼資料。 |
英文摘要 | The ICD-9-CM code will become the basis of payment directly under the Diagnosis Related Groups Payment System (DRGs), so that the hospital pays more attention to the code quality and reimbursement efficiency. The disease code comes from the doctor and coder mainly in the hospital, They all adopt ICD-9-CM reference book, but there are some variation entries between the doctor and coder in using the ICD-9-CM code, so most domestic hospitals will declared the ICD-9-CM code after encoding again through the coder. This research adopted the case that one medical center was permitted access to a Hospital for Respiratory Disease, This study collected 804 samples from the Pediatric and Chest Department from January 2004 to July 2004 and then analysed for the code consistency rate. The consistency rate includes the main diagnosis and secondary diagnosis. A well-trained coder can then review the medical records to find out the reason for variations between the doctor and coder. The results showed the Pediatrics and Chest Department consistency rate for the main diagnosis was 59.21% and 32.71%, which is significantly different to the 95% in a US study. In order to find the reason for inconsistencies in the code rates, a coding specialist was consulted to analyse the data, the results of which are summed up as follows: 1. The doctor should have used a combination code; 2. The doctor did not utilize the highest number of digits; 3. The doctor did not key in the final diagnosis into the medical database; 4. The doctor should use the high weight codes in multiple principle diagnosis. The results reveal the important of correct coding. In conclusion, hospitals should keep complete and accurate coding through the revised information system and process management and implement code training for doctors. |
本系統中英文摘要資訊取自各篇刊載內容。