泌尿生殖系統ICD-10-CM/PCS編碼一致性探討

Discussion on the Consistency of ICD-10-CM/PCS Coding in Genitourinary System

泌尿生殖系統相關疾病為常見住院原因之一，正確且一致的病歷編碼對醫療品質監測、健保支付與疾病統計均具關鍵意義。本研究為了解目前各層級部立醫院在泌尿系統疾病編碼實務上的準確性與一致性，由2023年衛生福利部所屬23家醫院的出院病歷中選取主要診斷ICD-10-CM編碼之前3碼為N39（泌尿系統其他疾患）或N13（阻塞性及逆流性泌尿道病變）者，以隨機抽樣方式，區域醫院及地區醫院分別每家抽樣10本及6本病歷，共計抽樣164本病歷。
主要診斷及主要處置的編碼一致率分別為91.46%及91.30%，不同醫院層級間並無顯著差異（p = 0.161及0.525）；所有診斷及所有處置的編碼一致率分別為97.73%及89.19%，不同醫院層級間並無顯著差異（p = 0.191及0.454）。進一步分析主診斷前三碼為N13的病例，發現主診斷一致率區域醫院顯著高於社區醫院（分別為92.68%及68.75%，p = 0.019），而所有診斷一致率，區域醫院亦顯著高於社區醫院（分別為96.95%及87.50%，p = 0.010）。
診斷編碼不一致主要原因包括：診斷不須編碼（佔34.15%）、診斷未使用合併碼（26.83%）、次診斷編碼錯誤（14.63%）等。處置編碼不一致主要原因包括：次要處置編碼錯誤（34.62%）、主要處置編碼錯誤（26.93%）、部位編碼錯誤（19.23%）。
泌尿生殖系統的編碼大多都有一定的共識及編碼的一致性。經由定期的病歷查核或外部編碼審查可發現存在的問題，進而建立標準作業流程及系統性檢核機制，以提升編碼的正確性及完整性。

Diseases of the genitourinary system are among the common causes of hospitalization, and accurate and consistent medical record coding is crucial for monitoring healthcare quality, determining insurance reimbursement, and compiling disease statistics. This study aimed to evaluate the accuracy and consistency of ICD-10 coding practices for urinary system diseases across different levels of government hospitals. From medical records in 2023 across 23 hospitals under the Ministry of Health and Welfare, cases with a primary diagnosis code starting with either N39 (Other disorders of urinary system) or N13 (Obstructive and reflux uropathy) were selected. A total of 164 medical records were randomly sampled, including 10 from each regional hospital and 6 from each district hospital.
The consistency rates for primary diagnosis and primary procedure coding were 91.46% and 91.30%, respectively, with no statistically significant differences across hospital levels (p = 0.161 and 0.525). The overall consistency rates for all diagnosis and all procedure codes were 97.73% and 89.19%, respectively, again showing no significant differences by hospital level (p = 0.191 and 0.454). Further analysis of cases with primary diagnosis codes starting with N13 revealed that regional hospitals had significantly higher consistency in primary diagnosis coding compared to district hospitals (92.68% vs. 68.75%, p = 0.019), as well as in overall diagnosis coding (96.95% vs. 87.50%, p = 0.010).
The main causes of inconsistency in diagnosis coding included: diagnoses that did not require coding (34.15%), failure to use combination codes (26.83%), and incorrect secondary diagnosis coding (14.63%). For procedure coding, discrepancies were mainly due to errors in secondary procedure coding (34.62%), primary procedure coding errors (26.93%), and incorrect coding of anatomical sites (19.23%).
In general, there is a well-established consensus and consistency in coding genitourinary system disorders. Regular audits and external reviews of the coding can help identify existing problems, leading to the development of standard operating procedures and systematic verification mechanisms to improve the accuracy and completeness of medical coding.