ACCURACY OF DIAGNOSTIC CODING FOR MEDICARE PATIENTS UNDER THE PROSPECTIVE-PAYMENT SYSTEM
ACCURACY OF DIAGNOSTIC CODING FOR MEDICARE PATIENTS UNDER THE PROSPECTIVE-PAYMENT SYSTEM
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DOI：
10.1056/nejm198802113180604
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发表时间：
1988-02-11
影响因子：
158.5
通讯作者：
KUSSEROW, RP
中科院分区：
文献类型：
--
作者：
HSIA, DC;KRUSHAT, WM;KUSSEROW, RP
根据预期支付制度，医疗保险对医院的补偿是基于病人出院时的诊断。在1984年10月至1985年3月期间，我们研究了接受医疗保险报销的医院中诊断相关组（DRGs）编码的准确性。我们采用两阶段聚类方法，从239家医院的7050份病历中抽取样本，这些医院根据规模进行分层。使用盲法技术和可靠性检查，病历专家重新提取了国际疾病分类第九版临床修改（ICD-9-CM）代码，为出院患者分配正确的DRG。然后将正确的DRGs与医生和医院管理部门最初分配的DRGs进行比较。该研究显示DRG编码的错误率为20.8%。错误在医生和医院之间平均分布。小医院的差错率明显较高。以前的研究发现，错误是随机发生的，因此一半的错误使医院在经济上受益，一半则使医院受到惩罚。目前的研究发现，统计上显著的61.7%的编码错误有利于医院。这些错误导致医院的平均病例组合指数（衡量医院患者疾病复杂性的指标）增加了1.9%。因此，医院从医疗保险中获得的净报销额高于医疗记录所能支持的数额。我们的结论是，在DRGs的编码中确实发生了“蠕变”，导致医疗保险覆盖的患者向医院支付了过多的费用。
Reimbursement of hospitals by Medicare under the prospective-payment system is based on patients'' diagnoses as coded at discharge. During the period October 1984 through March 1985 we studied the accuracy of the coding for diagnosis-related groups (DRGs) in hospitals receiving Medicare reimbursement. We used a two-stage cluster method to sample 7050 medical records from 239 hospitals that were stratified according to size. Using blinded techniques with reliability checks, medical record specialists reabstracted the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to assign correct DRGs to discharge patients. The correct DRGs were then compared with those originally assigned by the physician and the hospital administration. The study revealed an error rate of 20.8 percent in DRG coding. Errors were distributed equally between physicians and hospitals. Small hospitals had significantly higher error rares. Previous studies had found that errors occurred randomly, so that half the errors benefited the hospital financially and half penalized the hospital. The present study found that a statistically significant 61.7 per cent of coding errors favored the hospital. These errors caused the average hospital''s case-mix index - a measure of the complexity of illness of the hospital''s patients - to increase by 1.9 percent. As a result, hospitals received higher net reimbursement from Medicare than was supportable by the medical records. We conclude the "creep" does occur in the coding of DRGs, resulting in overpayment to hospitals for patients covered by Medicare.