The Filling and Coding Quality of Major Diagnoses in Patients with Cirrhosis Complicated with Gastrointestinal Bleeding and the Influence on DRG Enrollment
Objectives To analyze the filling and coding quality of major diagnoses in patients with cirrhosis complicated with gastrointestinal bleeding and the influence on DRG enrollment,and provide help for the selection of major diagnoses and accurate coding and enrollment of patients discharged from hospital.Methods A total of 160 patients with cirrhosis complicated with digestive tract hemorrhage were retrieved from the medical record information system of a hospital from January 1st,2021 to December 31st,2022.The medical records were checked one by one,the main diagnostic defects were summarized,and the correct diagnosis selection and coding of patients with cirrhosis complicated with gastrointestinal bleeding were analyzed by Chi-square test in different departments.The CHS-DRG grouping was re-performed using the CHS-DRG grouping device to describe the DRG enrollment of patients before and after the modification.Result Among the 160 patients,the doctors incorrectly reported 80 major diagnoses,and the coders failed to correct the errors and made wrong coding.Gastrointestinal bleeding was the most common misdiagnosis for patients with cirrhosis complicated with gastrointestinal bleeding,including upper gastrointestinal bleeding or acute gastrointestinal bleeding.Compared with hepatology department and other departments,gastroenterology department had the lowest correct rate of main diagnosis selection,about 39.5%.The main diagnosis of patients with cirrhosis complicated with digestive tract bleeding was that cirrhosis with variceal rupture and bleeding enters the liver,biliary and pancreatic diseases and dysfunction(MDCH)group,while digestive tract bleeding was selected as the main diagnosis and enters the digestive system diseases and dysfunction(MDCG)group,which was the most common wrong inclusion situation.Conclusions We should strengthen professional training for clinicians and coders,including training on diagnosis and coding knowledge of specialized disciplines and diseases,strengthen communication between the two,establish and improve the case quality control and assessment system,so as to improve the filling and coding quality of major case diagnoses and the enrollment accuracy rate.
NETL
NSTL
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