코딩시뮬레이션을 이용한 의사 및 심사간호사와 의무기록사의 질병코딩 차이 연구
A Study on the Difference in Disease Coding of Doctors, Medical Insurance Review Nurses and Medical Record Administrators based on Coding Simulation
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Objectives: The objective of this study is to investigate the difference in disease coding of doctors, medical insurance review nurses and medical record administrators who are directly involved in disease coding in hospital. Methods: Thirteen virtual medical records were developed for common diseases. The study subjects were requested to select principal diagnosis and other diagnoses for the each record. The survey was conducted through web pages specially developed for coding simulation. 29 doctors, 74 medical insurance review nurses, and 100 medical record administrators participated in this survey. Results: There was large difference in the concordance rate between the study subjects’ answer and coding guidelines published by the National Statistical Office. Concordance rate was high in medical record administrators (93.6%) but low in doctors (43.1%) and medical insurance review nurses (35.6%). The difference was noticeable in the way of using Z codes as principal diagnosis. Also large difference existed in the way of coding symptom under treatment and underlying disease. Conclusions: This study shows that there are large differences in disease coding depending on the occupation. To decrease this difference, it is needed to refine the coding guidelines and strengthen the education about them.
Abstract
Objectives: The objective of this study is to investigate the difference in disease coding of doctors, medical insurance review nurses and medical record administrators who are directly involved in disease coding in hospital. Methods: Thirteen virtual medical records were developed for common diseases. The study subjects were requested to select principal diagnosis and other diagnoses for the each record. The survey was conducted through web pages specially developed for coding simulation. 29 doctors, 74 medical insurance review nurses, and 100 medical record administrators participated in this survey. Results: There was large difference in the concordance rate between the study subjects’ answer and coding guidelines published by the National Statistical Office. Concordance rate was high in medical record administrators (93.6%) but low in doctors (43.1%) and medical insurance review nurses (35.6%). The difference was noticeable in the way of using Z codes as principal diagnosis. Also large difference existed in the way of coding symptom under treatment and underlying disease. Conclusions: This study shows that there are large differences in disease coding depending on the occupation. To decrease this difference, it is needed to refine the coding guidelines and strengthen the education about them.
참고문헌 (14)
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