醫師與疾病分類人員ICD-9-CM編碼不一致因素之探討

Exploring the Factors of ICD-9-CM Coding Inconsistency between Physicians and Coding Staff

目標：比較醫師與疾病分類人員兩者病歷編碼的一致性，並探討編碼一致性影響因素。方法：兩階段研究。第一階段以南部某財團法人醫學中心，主治醫師與疾病分類人員針對同一病歷分別編碼，比較其編碼一致性，並進行疾病特質、醫師特質等影響因素分析。第二階段以質性深度訪談方式，探討二者對於影響編碼不一致因素的認知，以建立未來可供實證之命題。結果：所有診斷處置代碼中有17%一致，DRGs點數則醫師編碼較疾病分類人員低1,478,932點。是否接受手術處置與是否有合併症／併發症皆造成編碼一致性的差異。本研究也發現，醫師與疾病分類人員對疾病的診斷及治療認知程度不同、病歷書寫品質，與醫師對編碼規則的不熟悉皆為造成編碼不一致的主要因素。結論：在ICD-10-CM/PCS已然上路，疾病分類規則愈精細複雜之際，上述相關因素有必要釐清與改善，以達到醫師與疾病分類人員之共識、增進管理效能；以提供更精確的疾病編碼品質。

Objectives: To compare the ICD-9-CM coding made by the physician with the same coding by the coding staff, and explore the influencing factors of coding inconsistency between them. Methods: We utilized a two-phase study. In phase one, we visited a southern Foundation Medical Center of Taiwan and asked their coding staff and attending physicians to encode ICD-9-CM for some of their medical records without consulting each other. The outcomes were compared for the inconsistencies between them and differences in disease characteristics and physician factors analyzed. In phase two, through detailed discussions with all involved, the study explored the influencing factors of the inconsistency and constructed future research propositions using a qualitative approach. Results: Of all diagnostic medical records studied, there was 17% consentient between the physicians and the coding staff. The DRGs weight coded by the coding staff was 1,478,932 points higher than that by the physicians. There were inconsistencies of coding between factors including with/without operational procedure, with/without complications/comorbilities, and medical record writing quality. The study also found the influencing factors of inconsistency including that the physicians were not that familiar with the coding rules, and different cognitions between the physicians and coding staff on diagnosis and treatment of certain diseases. Conclusions: Ministry of Health and Welfare has already scheduled to replace the current version with ICD-10-CM/PCS in the near future, a much more elaborate and complex new classification system. This research suggests that hospitals have to find a sure way soon to get rid of the inconsistency of coding between their physicians and coding staff as well as to build their consensus, so as to provide a more accurate coding quality, and enhance management efficiency.