近年來醫療費用不斷上漲,健保醫療財務已入不敷出,在二代健保改革聲浪四起時,健保局預計於2008年推行DRGs支付制度,並以DRGs之權值點數換算為醫療償付金額。因此,疾病分類人員如何依據病歷記載,正確的對疾病與手術處置編碼,遂成為醫療償付之重要關鍵。 不正確的編碼品質無法有效反映醫療成本及醫療品質,進而無法合理分配醫療資源。因此,本研究期望建立健保手術醫令比對ICD處置碼對應檔,期能應用於手術醫令預審及DRGs編碼資訊系統,縮短處置編碼時間,並提升編碼之準確性與完整性。 經由Kappa檢定對應檔的一致性其值為0.56趨近Good agreement,將其對應檔應用於健保手術預審後發現確實可提升病歷處置書寫完整性、疾病分類人員處置編碼及申報人員手術醫令申報之正確性。建議未來持續進行並擴大健保醫令比對ICD處置對應檔,以增進ICD處置碼及申報健保醫令碼之正確性,並提升醫令預審效益及疾病分類人員編審之一致性。
Medical expenditure has increased rapidly in the recent years. The Bureau of National Health Insurance plans to implement a DRGs based reimbursement system in 2008 to cope with the second generation reform of National Health Insurance. Suppliers under this system would be reimbursed based on DRGs weighted utilization. How to improve coding quality and accuracy for disease classification based on patient records is thus an important element for this reimbursement system. Imprecise coding would not reflect actual medical cost and quality, and thus would lead to inefficient medical resource allocation. This research aims to use information system to develop a mapping file for surgery orders in accordance with surgical related procedure. This would aid in pre-assessment for surgery orders and DRGs coding information system, and reduce time required for coding and improving precision and accuracy. We use kappa statistics to test mapping file agreement and we found k=0.56 that it’s trend toward good agreement. It is recommended that in order to increase the efficiency of pre-assessment and consistency of disease classification, matching medical orders and ICD code mapping database should be continued, and the scope of comparison should be increased to improve accuracy.