疾病分類人員對診斷編碼的建議對健保支付費用與DRG點數之初探性研究－以台某市某區域醫院爲例

Objectives: Coders of the disease classification in hospitals sometimes
give advice to the attending physician on changing the coding of the inpatient
cases when filing claims to the National Health Insurance (NHI). This study
aimed to examine factors associated with the likelihood that the advice was
being taken; and once the advice is taken, how would the payments change
under NHI.
Methods: The study took its sample from 99 inpatients cases which took
advise from medical record management staffs to change their coding of disease
classification at a regional hospital located in Taipei in October of 2005. The
data was derived from linking the records of advices made by medical record
management staffs and medical record and inpatient claims data to NHI. Chisqurare
tests were performed to examine whether type of coding advice and
specialty of the attending physician were associated with the likelihood that the
advice was being accepted; and whether there were any differences in the
reimbursed payments.
Results: Of the 99 study cases, 70 cases accepted the advice to change the
coding and the reimbursement amount increased by NT$ 1,497,672, which
equaled 0.36% of all NHI reimbursement in the month of the hospital under
study. Cases with comorbidity and/or complications which were advised to switch from claiming under the case payment to the fee for service had the
highest increase in reimbursement amount, compared to the other types of
cases. Cases from the Department of Cardiology or Cardiovascular Surgery had
significantly higher reimbursement amounts than cases from the other
departments. No significantly differences in reimbursement points under
Diagnostic Related Groups (DRG) system were found in this study.
Conclusions: Advices of changing codes from the coders of disease
classification substantially increased the reimbursement amounts but did not
change the reimbursement points under DRGs system.