| Abstract: | Currently, fee-for-service based reimbursement scheme has led to inefficient distribution of medical resources. Therefore, Bureau of National Health Insurance intends to develop other predictable budget scheme, including Prospective Payment System (PPS). In addition, the authority plans to implement new payment standard for inpatient medical services based on Diagnosis Related Groups (DRGs) in year 2006. The DRG classification principle is based on ICD-9-CM code. Thus, if a medical record can?t be completed by the deadline of filing insurance claims, it may lead to incomplete or inaccurate coding, and further impacts on the financial revenues of a hospital.
The purpose of this thesis aims to discuss the inconsistency of ICD coding as well as the impacts on DRG and Case Mix Index (i.e, CMI) when medical records were not completed and reported by scheduled time of filing insurance claims. Furthermore, this study analyzed the effects of a rewarding policy for in-time completion of medical records. The discharged medical records of a private medical center were collected as our sources of data. Since the rewarding policy was put into operation on September, 2004, this study collected discharged medical records of June to August and September to November of Year 2004 as our case groups, with discharged medical records of June to August and September to November of Year 2003 chosen as our compared groups. This study employed Brio Software, Microsoft Excel, and SPSS software (version 10th) to proceed various binary analyses. The major findings and suggestions show as follows.
(1) Incomplete medical records by the scheduled time of filing insurance claims have led to overall inconsistent coding from 19% to 26%, depending on the case or comparison groups, and further inconsistent coding from 6% to 55%, depending on medical departments. Among these medical departments, Dept. of Rehabilitation, Family Medicine, Hematology, Chest Medicine, Cardiology, Breast Surgery, Thoracic Surgery, Digestive Surgery, and Cardiovascular Surgery showed higher percentage of inconsistent coding. In addition, inconsistency of major diagnosis, omission of secondary diagnosis, and omission left on major procedure coding constitute most of the inconsistency.
(2) Inconsistent ICD coding led to the significantly changes of DRG ranged from 6.3% to 9%. Also, the value of CMI significantly increased from previous 1.14% to 2.06% afterward. The same situation applied to the numbers of secondary diagnosis coding .
(3) The reward-driven policy statistically worked for residents from 1.6% of incomplete medical records to 0.03%. It also worked for attending physicians from 7.5% of incomplete medical records to 6.5%. The percentage of inconsistent ICD coding decreased significantly from 26% to 19%. Moreover, the increased relative values of DRGs, enlarged potential revenues. The study hospital, as an example, was estimated to avoid potential loss of nearly 5.5 million NT dollars, should DRG-based payment system was implemented at this moment.
This study suggests that the health authority should provide a consistent, unified medical record writing model, as well as more thorough peer-review mechanism to improve the consistency of ICD coding. Meanwhile, we also suggest that the hospital administration should use ways and means to manage incomplete medical records, as well as more monitoring toward inaccurate ICD coding. At last, this study make a contribution by offering a useful guide to common causes of ICD coding. |
