| 摘要: | 背景：ICD-9-CM之架構，已無法滿足新興疾病及醫療技術變化在分類上的需求，美國於2013年10月起將以ICD-10-CM/PCS 取代之，並為確保轉換ICD版本的過渡時期國家資料的一致性，美國老人、殘障及貧民健保局(Center for Medicare & Medicaid Services, CMS)建置ICD-9-CM和ICD-10-CM/PCS的對應檔。目的：本研究主要探討，直接以資訊技術(Information technology, IT)使用對應檔轉換代碼進行申報對於現行的Tw-DRGs支付制度之影響。方法：2010年健保資料庫之區域醫院住院申報資料為資料來源，使用對應檔以IT直接轉換ICD版本，重新進行Tw-DRGs編審後，DRG分派改變之129,525件住院案件為研究對象，進行轉換前後之醫院病例組合指標與申報費用之比較分析，然在一對多對應之案件，本研究則選擇轉換後之權重最小值與最大值為之。結果：轉換後分派DRG與原始DRG不同，佔12.36%。DRG改變之原因有主要疾病類別改變、 DRG內外科系改變、嚴重度改變及處置無對應碼。對應轉換後以最小權重申報費用比轉換前申報費用顯著減少之醫院有39家，而比轉換前申報費用顯著增加之醫院有25家；以最大權重申報費用，比轉換前申報費用顯著增加之醫院有53家，比轉換前申報費用顯著減少之醫院有14家。結論：使用對應檔進行ICD-9-CM代碼轉換時，除須考慮使用的對應檔版本，還要臨床醫師與疾病分類專家共同訂定轉換規則，以提高對應轉換之正確性。
Background: The structure of ICD-9-CM has not allowed new diseases and procedures associated with rapidly changing technology to be effectively incorporated as new codes. ICD-10-CM/PCS has been mandated as the new code set to be used for medical coding in the United States beginning on October 1, 2013, replacing the current ICD-9-CM. To ensure the consistency of national data during the transition period prior to ICD-10-CM/PCS implementation, the Centers for Medicare & Medicaid Services (CMS) developed a general equivalent mapping (GEM) system for sourcing and replacing codes and code lists. Objective: The study attempted to examine the effects of GEM via information technology (IT) on Tw-DRGs payment system for implementation of ICD-10-CM/PCS. Methods: The study selected regional hospital inpatient claims for Tw-DRG cases from 2010 National Health Insurance (NHI) reimbursement database. Mapping case’s ICD-9-CM diagnosis and procedure codes to ICD-10-CM/PCS and vice versa was directly converted by GEM via IT. The cases with change in Tw-DRG 3.3 assignment after the GEM conversion were selected for comparing the hospital case mix index and payment between pre- and post-GEM mapping, the smallest and largest relative weight were used for comparison when the GEM mapped many options. Results: After forward and backward mappings using GEM, of the 1,048,359 Tw-DRG cases, 129,252 (12.36%) cases had changes in Tw-DRG assignment. The changes in Tw-DRG assignment were due to the major diagnostic category change, difference in medical and surgical categories, severity change and procedure’s no reasonable mapping. When hospital reimbursement claim with the smallest relative weight of post-mapping DRG, there were thirty-nine hospitals’ payment would decrease significantly, while the payment would increase significantly in twenty-five hospitals; when choosing the largest value of relative weight of post-mapping DRG to claim, there were fifty-three hospitals’ payment would increase significantly, however, fourteen hospitals’ payment would decrease significantly. Conclusions: The results of this study suggest that applying GEM to ICD-9-CM for ICD-10-CM/PCS transition should be aware of GEM version and take the manual evaluation and expert decision making about code lists into account, instead of only mapping via IT. |
