[1]邹灿英.住院病案首页ICD编码质控前后的差异性及分值变化[J].医学信息,2020,33(21):11-13.[doi:10.3969/j.issn.1006-1959.2020.21.004]
　ZOU Can-ying.Differences and Score Changes Before and After Quality Control of ICD Codes on the First Page of Hospitalized Medical Records[J].Medical Information,2020,33(21):11-13.[doi:10.3969/j.issn.1006-1959.2020.21.004]
点击复制

住院病案首页ICD编码质控前后的差异性及分值变化()
分享到：

医学信息[ISSN:1006-1959/CN:61-1278/R]

卷:
33卷
期数:
2020年21期
页码:
11-13
栏目:
出版日期:
2020-11-01

文章信息/Info

Title:
Differences and Score Changes Before and After Quality Control of ICD Codes on the First Page of Hospitalized Medical Records
文章编号:
1006-1959（2020）21-0011-03
作者:
邹灿英
（罗定市人民医院质控科/病案室，广东 罗定 527200）
Author(s):
ZOU Can-ying
(Quality Control Department/Medical Record Room,Luoding People’s Hospital,Luoding 527200,Guangdong,China)
关键词:
ICD编码; 质控; 住院病案首页; 医保结算
Keywords:
ICD code; Quality control; Hospitalization medical record homepage; Medical insurance settlement
分类号:
R197.3
DOI:
10.3969/j.issn.1006-1959.2020.21.004
文献标志码:
B
摘要:
目的 分析住院病案首页ICD编码质量控制前后差异性和分值变化，探讨获得准确医保结算总额的方法。方法 选择我院2019年2月~2020年5月肝癌介入治疗、乳腺癌局部扩大切除术和化疗药物灌注的出院病例，将上述3个疾病诊断相关分组（DGRs）质控前的病例纳入对照组，质控后的DRGs病例纳入研究组，比较两组分值均值、病种分值、化疗药物灌注的病种分值差异及总分值变化情况。结果 对照组肝癌介入治疗、乳腺癌局部扩大切除术和化疗药物灌注的分值分别为（562.42±20.36）、（998.15±20.26）、（279.23±11.02），研究组上述DGRs分组分值分别为（562.12±20.36）、（988.62±21.03）、（278.98±12.62），两组的DGRs分组分值均值比较，差异无统计学意义（P＞0.05）；对照组总分值为234940分，研究组质控后的合计分值为444248分，研究组比对照组的总分值增加了9.47%；研究组化疗药物灌注10例病例的治疗费用均超过200%，其分值减少1582分，下降27.80%。结论 对病案首页ICD编码进行质控，可保证编码准确，以获得准确的医保结算总额。
Abstract:
Objective To analyze the differences and score changes before and after the quality control of ICD coding on the first page of inpatient medical records, and to explore the method of obtaining accurate medical insurance settlement.Methods We selected discharged patients from our hospital from February 2019 to May 2020 who received interventional therapy for liver cancer, expanded local resection of breast cancer, and chemotherapy drug infusion, and included the above three disease diagnosis-related groups (DGRs) before quality control into the control group,the DRGs cases after quality control were included in the study group, and the mean value of the two components, the score of the disease type, the difference of the score of the disease type of chemotherapy drug infusion and the change of the total score were compared.Results The scores of interventional therapy for liver cancer, local extended resection of breast cancer and chemotherapy drug infusion in the control group were (562.42±20.36), (998.15±20.26), (279.23±11.02), and the above DGRs in the study group were (562.12±20.36), (988.62±21.03), (278.98±12.62), there was no significant difference in the mean value of DGRs between the two groups (P>0.05); the total score of the control group was 234940 points, and the quality of the study group the total score after control was 444248 points, which was an increase of 9.47% in the study group compared with the total score of the control group; the treatment cost of the 10 cases of chemotherapy drug infusion in the study group exceeded 200%, and the score decreased by 1582 points, a 27.80% decrease.Conclusion The quality control of the ICD code on the first page of the medical record could ensure the accuracy of the code and obtain an accurate total medical insurance settlement.

参考文献/References:

[1]陈贤展,尹龙燕.住院病案首页ICD编码质量对分值付费的影响[J].中国病案,2019(7):18-21.[2]张清霞,彭传薇,贺美林,等.PDCA在病种分值付费下病案首页质量控制管理的应用[C]//第二十七届中国医院协会病案管理专业委员会学术会议.2018.[3]高妍,李卫红,孙鹏.病案首页中呼吸机使用数据填报质量分析[J].中国病案,2015(10):27-29.[4]朱明宇.基于医学人工智能技术的病案首页智能编码研究[J].中国数字医学,2018,13(4):34-36.[5]岳海淑,董艳青,陈洁.住院病案首页主要诊断质量缺陷案例分析[J].中国病案,2019,20(6):11-13.[6]李称.使用PDCA循环的管理办法提高病案ICD-10编码的准确率分析[J].中国保健营养,2019,29(13):329.[7]梁景星,谢丽玲,周婷婷,等.基于DRGs付款下高倍率病例的病案首页诊断与手术操作填写和编码缺陷分析[J].中国医院统计,2019,26(4):307-310.[8]翁志雄,曾小军.2018年某三甲医院病案编码质量分析与改进措施[C]//第二十八届中国医院协会病案专业委员会学术会议.2019.

相似文献/References:

[1]李增芳,丁松瑞,赵 敏,等.公立医院绩效考核背景下某医院病历档案首页常见问题分析[J].医学信息,2020,33(22):145.[doi:10.3969/j.issn.1006-1959.2020.22.041]
　LI Zeng-fang,DING Song-rui,ZHAO Min,et al.Analysis of Common Problems on the First Page of Medical Records of a Hospital Under the Background of Performance Assessment in Public Hospitals[J].Medical Information,2020,33(21):145.[doi:10.3969/j.issn.1006-1959.2020.22.041]
[2]肖 婷.基于DIP付费模式下对ICD编码质量的思考[J].医学信息,2022,35(01):35.[doi:10.3969/j.issn.1006-1959.2022.01.008]
　XIAO Ting.Thoughts on ICD Coding Quality Based on DIP Payment Mode[J].Medical Information,2022,35(21):35.[doi:10.3969/j.issn.1006-1959.2022.01.008]
[3]王 森,王 瑞,孟青慧,等.基于临床业务的单病种质控及管理系统的设计与实现[J].医学信息,2023,36(19):1.[doi:10.3969/j.issn.1006-1959.2023.19.001]
　WANG Sen,WANG Rui,MENG Qing-hui,et al.Design and Implementation of a Single Disease Germplasm Control and Management System Based on Clinical Business[J].Medical Information,2023,36(21):1.[doi:10.3969/j.issn.1006-1959.2023.19.001]
[4]展定莹.术后状态编码在病案首页的正确应用[J].医学信息,2024,37(06):47.[doi:10.3969/j.issn.1006-1959.2024.06.008]
　ZHAN Ding-ying.Correct Application of Postoperative Status Coding in the Front Page of Medical Records[J].Medical Information,2024,37(21):47.[doi:10.3969/j.issn.1006-1959.2024.06.008]

更新日期/Last Update: 1900-01-01