DRG病例分组错误与费用结算申诉探讨

Discussion on DRG Case Grouping Error and Fee Settlement Appeal

DRG点数付费制度实施后,杭州市某儿童专科医院发现由于住院病例病案首页主要诊断和主要手术填写不当导致病例DRG分组不合理、医保结算费用出现偏差.经分析、修改、申诉后,部分病例分组得到调整,医保结算费用趋于正常.研究在归纳整理申诉病例住院病案首页中诊断和手术存在问题的基础上,对编码方式及DRG分组方案进行分析,为提升住院病案首页填写质量和病例分组准确率、促进DRG付费的高效运行提供参考.

After the implementation of the DRG point payment system,a children’s specialized hospital in Hangzhou found that due to improper filling of the main diagnosis and main operations on the first page of the inpatient medical records,the DRG grouping of cases was unreasonable and the medical insurance settlement fees were deviated.After analysis,revision,and appeal,the grouping of some cases has been adjusted,and the medical insurance settlement fee has become normal.On the basis of summarizing and sorting out the problems of diagnosis and operation in the homepage of the hospital medical records of the appeal cases,the study analyzes the coding method and the DRG grouping scheme,so as to provide a reference for improving the filling quality of the homepage of the hospital medical records and the accuracy of case grouping,and promoting the efficient operation of DRG payment.