全民健康保險下疾病分類編碼品質與相關影響因素研究

Study on the Quality and Its Related Factors of International Classification of Disease Coding System in National Health Insurance

賴憲堂(Hsien-Tang Lai) ； 楊志良(Chih-Liang Yaung) ； 范碧玉(Bih-Yuh Fan)

《中華公共衛生雜誌》 17卷4期 (1998/08) Pp. 337-348

https://doi.org/10.6288/CJPH1998-17-04-07

摘要

我國已實施全民健保，目前正逐步實施論病例計酬支付制度，未來將進一步實施診斷關係群前瞻性支付制度(DRG/PPS)，故疾病分類編碼將成為醫院獲得有利醫療償付的重要媒介，在此一關鍵時刻急需評估全民健保實施後的疾病分類編碼品質及探討其影響因素，並提高其品質。本研究以八十四年九月份健保局之住院抽樣審查樣本為母全體，分層隨機抽取1,300件樣本進行疾病分類專家第二次編碼審查，並比較原始疾病分類編碼與專家第二次編碼間之一致性，以判斷原始疾病分類編碼正確與否，進一步並訪查該病例之原始疾病分類人員的各項基本特質，探討影響疾病分類編碼品質之相關因素。
研究結果發現63%的病例其疾病分類編碼至少有一個以上的錯誤。平均每個病例之疾病分類編碼錯誤率為35.56%，平均每個病例的編碼錯誤數為1.42個，而整體疾病分類編碼錯誤率為52%，其中主診斷之錯誤率為33%，主處置之錯誤率為39%。而影響疾病分類編碼品質的因素則發現醫院權屬別、評鑑級別、規模（床數）對疾病分類編碼品質均有統計上顯著影響。其中財團法人醫院優於公、和立醫院，但公、私立醫院間無顯著差異。醫學中心、區域醫院均優於地區醫院，而醫學中心與區域醫院間無顯著差異。此外疾病分類甄審資格、每月疾病分類工作負荷量、每日疾病分類工作時數對疾病分類編碼品質均有統計上顯著影響。

關鍵字

全民健康保險 ； 國際疾病分類 ； 疾病分類編碼品質

並列摘要

Taiwan has implemented the National Health Insurance (NHI) program, and DRG based prospective payment system will be adopted. Under DRG/PPS, the coding of disease classification certainly relates directly to the payment rate. To transit from fee-for-service system to prospective payment system, it is imperative to evaluate the coding quality of disease classification, to understand its influencing factors, and to study how to improve the quality of coding.
The study used a stratified sample of 1,300 inpatient cases from the NHI claim data in September, 1995. The discharge summary of these cases were reviewed and recoded by coding specialists to compare with the original coding. The characteristics of the original coders were also collected in order to explore the related factors affecting the quality of disease classification.
The study found that there were 63%of the study cases with at least one coding error. The average rate and number of miscoding for each case was 35.56% and 1.42, respectively. The overall rate of coding errors of the whole sample was 52%. Among the errors, 33% occurred in the principal diagnosis, and 39% were due to coding errors in the principal procedure.
Ownership, accreditation level and the scale(number of beds) of hospitals were found to be significantly important in determining coding quality. The coding quality of the proprietary hospital was better than that of those public and private hospitals. However, there was no significant difference in coding quality between public and private hospitals. Both medical centers and regional hospitals had better coding quality than district hospitals did, whereas no significant difference was found between medical centers and regional hospitals. In addition, coding qualification of coders, the work load of coders per month, and the time devoted to disease coding per day were also important determinants of coding quality.

並列關鍵字

National Health Insurance ； International classification of diseases ； Coding quality