基于病种付费大数据下ICD编码智能质控系统的开发与应用  

Development and Application of ICD Coding Intelligent Quality Control System Based on Big Data with Disease Type Payment

作　　者：袁素华[1] 李毅莲 Yuan Suhua;Li Yilian(XiaoLan People's Hospital of ZhongShan,Zhongshan Guangdong 528415,China)

机构地区：[1]中山市小榄人民医院,广东中山528415

出　　处：《医疗装备》2023年第13期1-5,共5页Medical Equipment

基　　金：中山市社会公益与基础研究项目(2020B1094)。

摘　　要：随着我国人口老龄化趋势进一步加剧,居民过快增长的医疗费用为医保基金带来了巨大压力。为减轻医保压力,国家推行按病种进行医保支付的方法。病种付费制是以病案首页中主要诊断(ICD-10)编码及手术与操作诊断(ICD-9-CM-3)编码为分值计算依据,在总额预算内根据病种的次均费用确定分值,继而进行结算医疗费用。诊疗信息的ICD编码是病种分组的关键依据,编码质量会对各医院的医保费用造成直接影响。该研究将信息处理技术与医院病案管理相结合,探索一种人工智能审核质控新模式,以期待可智能发现病案首页ICD编码错误,并提示编码质控人员及时修改,最终达到提高编码准确率的目的。经实践,该人工智能质控系统可有效提高编码正确率及病案编码人员工作效率,增加医院病史科、质控科的有效人力,有效减少因编码错误而导致的医保损失。With the further aggravation of the aging society in our country,the rapidly increasing medical expenses of residents have brought enormous pressure to the medical insurance fund.In order to alleviate the pressure of medical insurance,the method of paying by medical insurance based on the type of disease has been implemented by the country.With the main diagnostic(ICD-10)code and surgical and operational diagnostic(ICD-9-CM-3)code on the homepage of the medical record as the basis for score calculation,the disease type payment system determines the score based on the average cost of the disease type within the total budget,and then settles medical expenses.The ICD coding of diagnosis and treatment information is the key basis for disease grouping,and the quality of coding directly affects the medical insurance costs of each hospital.In this study,with the integration of information processing technology and hospital medical record management,a new quality control model with artificial intelligence auditing was explored,hoping to intelligently detect ICD coding errors on the front page of medical records and prompt coding quality control personnel to make timely modifications,ultimately achieving the goal of improving coding accuracy.Through practice,artificial intelligence quality control systems can effectively improve coding accuracy,improve the work efficiency of medical record coding personnel,increase the effective manpower of hospital medical history and quality control departments,and effectively reduce medical insurance losses caused by coding errors.

关 键 词：ICD编码 人工智能 医院管理 

分 类 号：R197[医药卫生—卫生事业管理]