ICD-10-CM-PCS編碼系統導入之經驗分享

Sharing the Experience of ICD-10-CM-PCS Coding System Implementation

衛生福利部中央健保署已公告將於2016年實施門、住診醫療費用全面採International Statistical Classification of Disease and Related Health Problems, Tenth Revision, Clinical Modification（以下簡稱ICD-10-CM）及Procedure Coding System（以下簡稱PCS）單軌申報，疾病統計一併改以ICD-10-CM/PCS統計，Tw-DRG支付亦併同修正為ICD-10-CM/PCS版本申報；本院本著配合國家政策推動，與世界接軌之動機，於2012年率先參與健保署「特約醫院ICD-10-CM/PCS小型先驅計畫」，成功建立ICD-10-CM/PCS導入的模式，2013年起再以院內研究計畫延續ICD-10-CM/PCS之改版作業，透過專案編組及專業分工與合作，將導入之作業模式擴展至全院科別，建立全院臨床醫師對ICD-10-CM/PCS編碼之認識，並配合ICD-10-CM/PCS編碼規則，研擬病歷寫作標準模式及資訊系統導入的需求，另透過病歷實作給碼經驗，培養疾病分析師對ICD-10-CM/PCS編碼實務經驗，建立各科之教案範本。目前門、急、住診之ICD-10-CM/PCS給碼查詢作業系統功能已經完成，雖然健保署公告延後一年實施，本院及所屬分院（院區）仍按原定期程於2015年1月5日正式上線，醫師及疾分師正式執行雙軌給碼作業，由臨床醫師於門、急、住診系統實作給碼，建立完整的ICD-10版本之資料庫，透過資料庫的統計及分析，作為ICD-10-CM/PCS版DRG的試算基礎及宣導教案，期望2016年全面上線能達成無縫接軌任務。

National Health Insurance Administration (NHIA), Ministry of Health and Welfare has announced recently that it’s going to thoroughly implement ICD-10-CM/PCS Coding System in 2016 for its routine calculation of medical expenses, disease statistics preparation, and the application for Tw-DRG payments by clinic diagnostic operation and hospitalization. In order to cooperate with the above said policy and catch up with the world trend, we, at Tri-Service General Hospital, actively joined the “Small-Scale Pioneer Project of ICD-10-CM/PCS with Contributing Hospitals” held by the Administration in 2012 and successfully built us a viable introducing model for implementing ICD-10-CM/PCS. Afterward, we continued the revision work of ICD-10-CM/PCS with our intramural research projects since 2013. With establishing a separate task force for each and every department, utilizing professional specialization, and cooperation, we have managed to attain four achievements. First, we extended the initial implementation model to every department of the hospital. Second, we trained all clinics physicians to understand the ICD-10-CM/PCS Codes. Third, we drafted an SOP for writing proper medical records according to the code regulations and fulfill the system requirements of implementation. Finally, with practical experience of coding medical records, we have the disease classifier of every department trained to such a level that they are able to write up model health records of their own expertise.The query system of ICD-10-CM/PCS coding has now been completed. Even though NHIA has postponed the deadline for a year, we and our branch put the system online on Jan. 5, 2014. Since then our physicians and disease classifiers have been doing the coding work in the back-and-forth double-track system. We built up an integral database of ICD-10 version with practical coding of clinics, hospitalization, and emergency department system by clinicians. And we took the statistics and analysis of the database as the trail basis of DRG, ICD-10 version. We are looking forward to that we’ll be able to complete the overall launching in 2016 as scheduled without any fuss.