疾病分類人員對診斷編碼的建議對健保支付費用與DRG點數之初探性研究－以台某市某區域醫院爲例

The Impact of Advices of Changing ICD-9-CM Coding on the Payments under the National Health Insurance-A Case Study of a Regional Hospital in Taipei

林詠蓉(Yung-Jung Lin) ； 曾家琳(Chia-Lin Tseng) ； 湯澡薰(Chao-Hsiun Tang)

《醫務管理期刊》 9卷2期 (2008/06) Pp. 83-87

https://doi.org/10.6174/JHM2008.9(2).83

摘要

目的：本研究目的有二，首先在探討經疾病分類人員對住院案件提出診斷或處置等修正建議（以下簡稱診斷建議）後，診斷建議之類別與科別對診斷建議被接受與否之影響；其次，探討診斷建議被接受後，對健保之給付金額與DRG給付點數增減的影響。
方法：以台北市某區域醫院2005月10月中，曾經疾病分類管理人員提出診斷編碼建議之出院病例共99件做爲研究對象。串聯研究對象之住院醫療費用明細報表和診斷建議記錄後，以卡方檢定(chi-square test)檢定診斷建議之接受與否是否因診斷建議之內容性質及科別不同而有所差異，以及接受診斷建議後，不同診斷建議內容性質與科別對健保給付金額增減之影響是否有差異。
結果：本研究99件住院病例中，有70件個案接受了修改診斷的建議。根據診斷建議進行健保給付之申請時，可使當月收入增加l,497,672元，約佔當月總申報金額之0.36%。在現行健保支付制度下，診斷建議以歸類爲「論病例計酬案件病歷內容具有合併症及併發症診斷碼，得改以核實申報」者，對診斷建議被採納前後之健保給付差額影響最大；再者，對心臟血管外科和心臟血管內科所做之診斷建議，所造成之給付差額最大。然而，本研究並未曆現診斷建議之類別與科別，對診斷建議被採納前後之DRG給付點數差額具有顯著影響。
結論：診斷建議後疾病分類編碼或處置之改變顯著地提高現行健保之給付金額，但是對DRG之點數並無顯著之影響。

關鍵字

診斷關係群 ； 疾病分類 ； 病歷管理 ； 健保給付

並列摘要

Objectives: Coders of the disease classification in hospitals sometimes give advice to the attending physician on changing the coding of the inpatient cases when filing claims to the National Health Insurance (NHI). This study aimed to examine factors associated with the likelihood that the advice was being taken; and once the advice is taken, how would the payments change under NHI.
Methods: The study took its sample from 99 inpatients cases which took advise from medical record management staffs to change their coding of disease classification at a regional hospital located in Taipei in October of 2005. The data was derived from linking the records of advices made by medical record management staffs and medical record and inpatient claims data to NHI. Chisqurare tests were performed to examine whether type of coding advice and specialty of the attending physician were associated with the likelihood that the advice was being accepted; and whether there were any differences in the reimbursed payments.
Results: Of the 99 study cases, 70 cases accepted the advice to change the coding and the reimbursement amount increased by NT$ 1,497,672, which equaled 0.36% of all NHI reimbursement in the month of the hospital under study. Cases with comorbidity and/or complications which were advised to switch from claiming under the case payment to the fee for service had the highest increase in reimbursement amount, compared to the other types of cases. Cases from the Department of Cardiology or Cardiovascular Surgery had significantly higher reimbursement amounts than cases from the other departments. No significantly differences in reimbursement points under Diagnostic Related Groups (DRG) system were found in this study.
Conclusions: Advices of changing codes from the coders of disease classification substantially increased the reimbursement amounts but did not change the reimbursement points under DRGs system.

並列關鍵字

DRGs ； Disease Classification ； Medical Record Management ； Payment Mechanism National Health Insurance

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