某专科医院DRGs结算模式下未入组病例分析及改进措施  

Analysis of Non-Grouped Cases and Improvement Measures Under the DRGs Settlement Model in a Specialized Hospital

作　　者：王倩[1] 黄辉 付家亮 WANG Qian;HUANG Hui;FU Jialiang(Department of Medical,Xuzhou Maternity and Child Health Care Hospital,Xuzhou Jiangsu 221009,China)

机构地区：[1]徐州市妇幼保健院医务科,江苏徐州221009

出　　处：《中国卫生标准管理》2024年第1期74-77,共4页China Health Standard Management

摘　　要：目的分析某专科医院在疾病诊断相关组(diagnosis related groups,DRGs)结算模式下存在的未入组病例问题,并提出相应的改进措施。方法通过回顾性分析和专家讨论,选取并总结某专科医院2021年1月—2022年6月上传至市医保平台病例信息管理系统中病例33935例中未入组病例300例,并对所有的未入组病例进行深入分析。结果未入组病例原因主要为主要诊断编码或者手术编码为灰码、医保版本切换导致原本入组的有效主诊断变成无效主诊断、主要诊断编码国家临床版医保版没有做好对照和临床医师主要诊断选择错误等方面。结论通过对医院DRGs结算模式下未入组病例的全面分析,找到改进措施,不断加强对临床医师和编码员的培训、加强病案首页质控、加强信息系统建设,从而提高DRGs入组率。Objective To analyze the issues of non-grouped cases in a specialized hospital under the DRGs settlement model and propose corresponding improvement measures.Methods Through retrospective analysis and expert discussions,a total of 300 non-grouped cases were collected and analyzed from 33935 cases uploaded to the municipal medical insurance platform case information management system from January 2021 to June 2022 in a specialized hospital.Results The main reasons for nongrouped cases included gray codes for the primary diagnosis or procedure codes,changed in medical insurance versions resulting in the transformation of valid primary diagnoses into invalid ones,lack of proper comparison between the national clinical version and the medical insurance version for primary diagnosis codes,and errors in the selection of the main diagnosis by clinical physicians.Conclusion Through a comprehensive analysis of non-grouped cases under the hospital's DRGs settlement model,improvement measures can be identified,such as strengthening training for clinical physicians and coders,enhancing quality control of medical records,and improving information system construction,in order to improve the DRGs inclusion rate.

关 键 词：DRGs结算模式 未入组病例 病案首页 主要诊断 编码 编码员 

分 类 号：R197[医药卫生—卫生事业管理]