疾病分類編碼品質對住院醫療給付影響之研究

Kaohsiung Medical University Chung-Ho Memorial Hospital

黃瑞典(Ruei-Dian Huang) ； 柯成國(Chen-Guo Ker) ； 藍守仁(Shou-Jen Lan) ； 嚴雅音(Yea-Yin Yen)

《病歷資訊管理》 10卷1期 (2010/12) Pp. 12-26

https://doi.org/10.29741/JMHIM.201012.0002

摘要

健保局已經於2010年元月開始分5年逐步實施診斷關聯群(Tw-DRGs)支付制度。疾病分類人員儼然成爲此新支付制度中的要角，對醫院的病例組合指標(CMI)與醫療給付有著決定性的影響力。隨著重要性的增加，疾病分類人員更應遵循倫理原則，切勿隨意修改或取巧編碼而獲取不當的健保給付。本研究的目的是以已申報的回溯性住院資料，模擬改善疾病分類編碼品質後，對住院醫療給付的影響。以分層隨機抽樣法選取樣本病歷，交由6位疾病分類人員編碼審核，最後實際編碼審核706本。所有病歷的CMI值爲0.97，經試算系統推佑之最佳CMI值爲1.54，兩者的差值爲0.57，推估後可能增加的醫療給付佔總醫療給付的比率爲32.9%。經審核後，共計修正的本，修正前的CMI值爲1.00，而修正後則成爲1.26。修正個案推估後可能增加的醫療給付佔總醫療給付比率爲2.0%，與32.9%相比較，其佔率比爲6.1%。因此，透過Tw-DRGs試算系統最佳化推估之醫療給付差額中，大約有6.1%是實際可爭取到的部分。再以實際醫療給付來推估，平均每個出院個案可額外爭取到1,096點的醫療給付。建議醫院宜在疾病分類編碼品質方面加強投資，包括疾病分類人員之教育訓練、Tw-DRGs最佳化資訊系統、改善病歷書寫品質等，相信可爭取到更合理的醫療給付。

關鍵字

疾病分類編碼 ； 病例組合指標 ； 診斷關聯群

並列摘要

Payment system based on the Diagnostic Related Groups has been started in 2010 in Taiwan. There were 706 cases of medical record by stratified sampling depend on the proportion of year and office number from 2000 to 2006 in our hospital. These cases of medical record had been verified by six certified coding specialists. The CMI value of all 706 sample cases was 0.97. These results of 706 cases by DRs auditing system were 1.54 of the best CMI value, 0.57 of the difference of the CMI value, and 32.9% of payment difference proportion. After verifying by certified coding specialists, these results were 93 revised cases, 1.26 of the CMI value, 0.26 of the difference of the CMI value, and 2.0% of payment difference proportion. To compare the payment difference proportion between 2.0% and 32.9%, the odds rate was 6.1%. Therefore, through DRGs optimization estimates system 6.1% of medical benefit payment difference could be striven in reality Estimating with actual medical benefit payment, the extra average Relative Value Unit (RVU) per case was 1,096. Hospital could enforce more in ICD-coding quality for striving more rational medical benefit payment including Certified Coding Specialists, optimization information system and the quality of medical record.

並列關鍵字

International Classification of Diseases ICD ； Case Mix Index CMI ； Diagnostic Related Groups DRGs