Impact of medical record quality on the ICD-9-CM coding and Tw-DRGs assignment

• Main Authors: Hui-Chuan Kung, 龔惠娟
• Other Authors: 楊美雪
• Format: Others
• Language: zh-TW
• Published: 2010
• Online Access: http://ndltd.ncl.edu.tw/handle/27736202935143722537

碩士 === 嘉南藥理科技大學 === 醫療資訊管理研究所 === 98 === Objectives: The present study was conducted to illuminate the effects of medical record integrity on coding and Tw-DRGs assignment. Methods: Retrospective review of 396 medical records submitted DRGs for reimbursement differed from the database of disease coding during the fiscal year 2009 in a district hospital in Northern Taiwan. “Recodes” were carried out and then compared to the original codes. Furthermore, physicians’ and nursing specialists’ perspectives about medical record and Tw-DRGs payment system was gathered via self administered questionnaires. Statistical analysis was performed using descriptive analysis and paired t-test with SPSS. Results: The absence of complete documentation in patient medical records causing the DRG error, the main causes were incorrect principal diagnosis selection (197 records, 51%), missing secondary diagnosis (86 records, 21.8%), incorrect coding of principal diagnosis (34 records, 8.6%) and secondary diagnosis (34 records, 8.6%). The mean (+/- SD) DRG relative weight in the 34 incorrect coding of secondary diagnosis records and 86 missing secondary diagnosis records were 1.20+/-0.79 and 0.78+/-0.64, respectively. The DRG relative weight presented a significant difference resulting from complete and accurate documentation in the medical record, 0.86+/-0.64 (decrease) and 1.09+/- 0.77 (increase) with respect to incorrect coding of secondary diagnosis records and missing secondary diagnosis records (each p<0.001). Among 75 questionnaire respondents, 68 % of physicians and nursing specialists were aware that the principal diagnosis is defined as the condition to be chiefly responsible for occasioning the admission while 18.7 % recognized the principal diagnosis is defined as the most severe condition during the episode of care. Conclusions: The results showed that incorrect coding of secondary diagnosis relating to medical document insufficiency may lead to a decrease in DRG relative weight under the same clinical scenario. The healthcare organization should focus on ensuring accuracy and completeness in clinical documentation.