DRG支付方式下高编码对医保支付的影响及特征分析

The Impact and Characteristics of Upcoding on Medical Insurance Payment under DRG Payment Method

目的分析实施DRG模拟付费后高编码病例的特征以及对医保基金支付的影响,为开展针对性监管提供实证经验。方法2019年某城市使用国家CHS-DRG分组方案开展DRG模拟付费。从217家医疗机构2019年1月1日-2020年5月31日的所有出院病例中各简单随机抽取200份病历,总计43400份病历。组织当地资深的临床专家和ICD编码专家共同核对原始病历并提供规范的ICD编码,使用DRG分组器根据规范的ICD编码重新分组获得每个病例规范的DRG分组和权重。如果医院原始分组及权重高于专家提供的规范权重,病例被判定为存在高编码情况。由于该城市的DRG付费实施固定费率,原始平均权重和规范平均权重的差异比例等于医保为这些审查发现的高编码病例额外支付费用的比例。利用t检验、卡方分析和方差分析比较不同错误类型导致的权重变化差异。结果被专家判定为高编码3075份病案,涉及389组DRG,53.1%的高编码由于主要诊断编码填写不规范导致,52.4%的高编码病例发生在肿瘤、呼吸、神经和循环系统DRG组中,高编码病例的原始平均权重比规范平均权重高49.3%,医保额外支付2546万元费用。结论DRG支付方式下的高编码会增加医保支出,主要诊断错误是高编码的重要原因,肿瘤、呼吸、神经和循环系统DRG组高编码发生率更高,建议开展院内ICD编码培训减少因能力不足导致的编码错误。

Objectives This study aims to analyze the characteristics of upcoding cases after implementing the DRG payment system and its impact on the payment of medical insurance funds,so as to provide empirical experience for targeted supervision.Method Since 2019,a city used the national CHS-DRG grouping scheme to carry out DRG simulation payments.200 medical records were randomly selected from all discharged cases in 217medical institutions from January 1,2019 to May 31,2020,totaling 43400 medical records.Local experienced clinical experts and ICD coding experts were organized to check the original medical records and provide standardized ICD coding.The DRG grouper was used to re-group each case and obtain the standardized DRG group and weight for each case.If the original weight provided by the hospital was higher than the standardized weight provided by the experts,the case was considered to have high coding.As the city implemented a fixed DRG rate,the difference between the original average weight and the standardized average weight was the proportion of additional payment by medical insurance paid for these upcoding cases.The t-test,chi-square analysis,and ANOVA were used to compare the weight changes caused by different errors.Results 3075 cases were judged to be upcoded by experts,involving 389 groups of DRG.53.1%of upcoding cases had major diagnostic errors.52.4%of upcoding cases occurred in DRG groups related to tumors,respiratory,nervous,and circulatory systems.The original average weight of upcoding cases was 49.3%higher than the standardized average weight.Medical insurance paid an additional 25.46 million yuan.Conclusions Upcoding under DRG payment methods increased health insurance spending.The major diagnostic errors were important causes of upcoding.The tumors,respiratory,nervous,and circulatory DRG groups had relatively higher upcoding rates.It is recommended to conduct in-hospital ICD coding training to reduce unintended coding errors.