摘要
目的:基于DIP核心病种ICD编码质量和临床诊疗行为,探索构建DIP核心病种分类管理模式。方法:对四川省泸州市DIP核心病种(3179个)及其病例(1156035例)进行疾病诊断和手术操作编码核查,分析其编码异常类型及原因。结果:该市DIP核心病种的病例异常率为5.14%,病种异常率为5.66%,其中主要诊断选择错误涉及病种最多(83个,2.61%),主要手术操作漏报涉及病例最多(30394例,2.61%);最终构建以正常组、监管组、歧义组为监管维度的DIP核心病种分类管理模式。结论:提高病案数据质量,建立病种动态调整与纠偏机制,有利于提高医保基金监管精准性,确保医保付费公平有效。
Objective To explore the construction of a classification management model of DIP core diseases based on the ICD coding quality and clinical diagnosis and treatment behavior of DIP core diseases.Methods The disease diagnosis and surgical procedure codes of the core DIP diseases(3179 cases)and their cases(1156035 cases)in Luzhou City,Sichuan province were verified,and the types and cau-ses of abnormal coding were analyzed.Results The abnormal rate of DIP core disease cases was 5.14%,and the abnormal rate of disease types was 5.66%.Among them,the main diagnostic selection errors involved the most disease types(83,2.61%),and the main surgical ope-ration omissions involved the most cases(30394,2.61%).Finally,a DIP core disease classification management model with the normal group,the supervision group and the ambiguous group as the supervision core was constructed.Conclusion It is necessary to improve the quality of medical record data and establish a dynamic adjustment and correction mechanism for disease types,which is conducive to improving the accuracy of medical insurance fund supervision and ensuring fair and effective medical insurance payments.
作者
曾雪琴
黄伟
于伟
ZENG Xueqin;HUANG Wei;YU Wei(School of Humanities and Management,Southwest Medical University,Luzhou Sichuan 646000,China;不详)
基金
四川医事卫生法治研究中心课题“DIP支付改革背景下医保基金监管的治理模式和路径分析”(YF22-Q05)
四川医院管理和发展研究中心课题“DIP支付改革背景下安宁疗护的社会医疗保险参与现状与付费机制探讨”(SCYG2022-30)
西南医科大学社科联项目“泸州市基层医疗机构DIP支付改革实践研究”(22SKL0030)
四川省老龄事业与产业发展研究中心“医保支付方式改革背景下医养结合机构补偿机制研究”(XJLL2023012)
四川省医院协会2023年医院管理科研专项资金项目“DRG/DIP付费下医疗异化行为识别及监管研究”(YG2314)。
关键词
DIP
核心病种
分类管理
监管
DIP
core diseases
classification management
supervision
