基于诊断编码信息传递环节构建低码高编风险因素分析框架综述

Review on Constructing the Framework of Risk Factor Affecting DRG Upcoding from the Perspective of the Flow of Diagnostic Information

以诊断结果为导向的按疾病诊断相关分组(DRG)预付制,为医方自身利益最大化创造了机会,并导致了各类道德风险问题,其中危害最大的就是"低码高编"。文章通过对国内外现有低码高编行为相关文献进行回顾和综述,进一步梳理低码高编若干个风险环节并总结归类其医疗市场、编码相关人员、入组患者、DRG病例组合系统、监管与控制系统5大风险特征,最终基于诊断编码信息传递的关键环节构建低码高编风险因素分析框架,以为后续低码高编相关研究提供理论依据。

The diagnosis-oriented Diagnosis Related Group(DRG)prospective payment system provides opportunities for health providers to maximize their interests,and leads to various moral hazard problems,including the most harmful risk,DRG upcoding.It aims to review previous literatures regarding to upcoding,sort out several risk links,and to classify these links into five risk characteristics,including medical market,coding-related personnel,patients,case mix system and the control system of DRG.Finally,the analysis framework of risk factor affecting the DRG upcoding from the perspective of the flow of diagnostic information is constructed to provide a theoretical basis for subsequent research on DRG upcoding.