建立医保分值付费下首页专项质控体系

Establish a special quality control system for the homepage under the medical insurance score Payment

目的分析某医院在医保分值付费制度下上传的住院病案首页数据,找出提高首页数据质量并适应分值付费的对策。方法随机抽取2018年第四季度(专项质控前) 1万份和2019年第一季度(专项质控后) 1万份结算的上传医保的病案首页付费的数据作为研究对象,专项质控前后进行分值对比,分析偏差病例和非偏差病例的首页质量。结果随机抽取2018年第四季度1万份病例合计分值为1 216 361分(专项质控前)较2019年第一季度的1万份病例的合计分值则为1 485 673分(专项质控后)偏低。偏差病例(实际结算<分值付费50%或>2倍)和非偏差病例中存在以下主要缺陷:①主要诊断选择错误;②主要手术及操作选择错误;③其他诊断遗漏;④其他手术操作遗漏。由于上述4种缺陷导致病例入组有偏差,从而医保分值付费与实际结算的费用相差极大。结论根据医保分值付费入组规则,应针对性指导主要诊断和主要手术操作的选择,确保有效的手术操作填写的完整性。以保持病案编码的真实性为优先考虑,分值付费作参考。依照医保分值付费的结果提出对策,有效控制费用成本,减少不必要的医疗支出。

Objective Study the situation of front-page uploading medical insurance payment system in order to improve quality of data uploading complying with medical insurance payment policy. Methods Compare the settle accounts about data uploading on medical insurance payment system between February and March. Its aim is looking insight front-page quality of deviation and non-deviation cases retrospectively. Results Randomly selected 10 000 cases in the fourth quarter of 2018 with a total score of1 216 361 points( before special quality control) compared with the total score of 10 000 cases in the first quarter of 2019,which was 1 485 673 points( special quality control) After is low. There are 4 major defects in deviation( Total expense < 50% or >double according to medical insurance standard) and non-deviation cases: ①Incorrect major diagnosis selection;②Incorrect major operation procedure selection;③Other diagnosis omitting;④Other procedure omitting. Above 4 main defects contribute to difference between actual expense and medical insurance payment. Conclusion According to medical insurance score group assignation rule,doctors should be guided on major diagnosis and procedure selection. Make sure to cover all effective procedure completely. Keep coding correctly based on the truth prior to medical insurance score group assignation. We should make out solution such as reducing cost or controling unnecessary medical overheads on the basis of settle account of medical insurace payment.