基于风险管理理论的医保定点医院ICD编码上传规范化研究  

Studying onthe Standardization of Uploading ICD Code in Medical Insurance Designated Hospitals Based on Risk Management Theory

作　　者：詹亚梅 宣昭鹏[1] 窦义臣[1] 刘鸿声 Zhan Yamei(The First Affiliated Hospital to Jilin University,Changchun,P.R.China)

机构地区：[1]吉林大学附属一医院,吉林长春130000 [2]吉林省社会保险事业管理局

出　　处：《中国卫生事业管理》2021年第9期672-675,共4页Chinese Health Service Management

基　　金：吉林省科技发展计划项目(20140418099FG)。

摘　　要：目的:基于风险管理理论探讨医保定点医院ICD编码上传的规范化。方法:选取2019年吉林省内6家医保定点三甲医院上传至省医保局1800份患者病案资料,比较主要诊断选择正确率和ICD编码上传正确率,分析医院上传ICD编码现状。结果:6家医院主要诊断选择正确率与ICD编码正确率差异显著(P<0.05),主要诊断选择正确但编码错误比率高达26.56%。ICD编码上传准确率低的主要原因包括医师ICD编码知识缺乏、编码员专业素质水平和责任心不高、编码员审核缺失、医保管理部门对编码质量监管不充分、ICD编码数据库不统一和更新不及时等。结论:通过建立编码管理制度,完善编码上传工作流程;完善编码培训制度,提高编码员和医师编码知识水平;建立统一的ICD编码数据库;医保局加强上传编码质量监管等措施能够提高医保定点医院ICD编码上传的规范化。Objective To discuss the uploading standardization of ICD code in designated hospitals of medical insurance based on risk management theory.Methods Data of 1800 patients’medical records uploaded to the provincial medical insurance bureau was sampled from 6 designated hospitals in Jilin Province in 2019 to compare the accuracy of main diagnosis selection and the upload accuracy of ICD codes.Results There had significant difference in correct rate of main diagnosis selection and ICD coding among 6 hospitals(P<0.05).The rate of cases with correct main diagnosis but error coding was as high as 26.56%.The main reasons for the low accuracy of uploading ICD codes include the lack of doctors’ICD coding knowledge,coders’lower professional quality and sense of responsibility,deficiency of coders’review,inadequate supervision on coding quality from medical insurance administration,inconsistency and untimely updating of ICD code database.Conclusion It is suggested to establish coding management system,perfect coding upload workflow and coding training system to improve the coding knowledge of coders and doctors,establish unified ICD coding database,strengthen the quality supervision of upload coding by the medical insurance bureau,which can improve the standardization of ICD code upload in medical insurance designated hospitals.

关 键 词：医保 医院 ICD编码 风险管理 规范化 

分 类 号：R197.322[医药卫生—卫生事业管理]