Fritz J, Gaissmaier C, Volkmann R, Höntzsch D, Greschner H
Arztlicher Bereich, Berufsgenossenschaftliche Unfallklinik Tübingen.
Unfallchirurg. 1999 Feb;102(2):92-7. doi: 10.1007/s001130050379.
Since 1995 German health maintenance laws require hospitals to document and code all referrals, admissions and discharges using the 4-digit ICD. Operative procedures are documented and coded using the ICPM. Beginning in January 1996, reimbursement for health services requires a diagnosis-related billing and payment for special procedures. The decision for billing is based on documented diagnosis and therapy. This extended request for documentation makes an online access to diagnosis and therapy with a computer-assisted coding system advisable. In 1996 in our hospital each diagnosis and operation was manually documented and coded on a form. Since the beginning of 1997, documentation and coding has been exclusively computer-assisted. On the basis of documented diagnosis and therapy the computer provides the route of reimbursement. Retrospectively we evaluated the number of charged diagnosis-related billings and payments for special procedures from January to April of 1996 and 1997. It became evident that with computer-assisted documentation and coding the number of detected and charged diagnosis-related billings and payments for special procedures was significantly increased in comparison with the previous year.
自1995年起，德国的健康维护法要求医院使用4位数的国际疾病分类（ICD）对所有转诊、入院和出院情况进行记录和编码。手术操作则使用国际操作分类法（ICPM）进行记录和编码。从1996年1月开始，医疗服务报销需要进行与诊断相关的计费，并对特殊程序进行支付。计费决策基于记录在案的诊断和治疗情况。这种对文档记录的额外要求使得通过计算机辅助编码系统在线获取诊断和治疗信息变得可取。1996年，在我们医院，每个诊断和手术都通过手工在表格上进行记录和编码。自1997年初以来，记录和编码工作完全由计算机辅助完成。根据记录在案的诊断和治疗情况，计算机提供报销途径。我们回顾性地评估了1996年和1997年1月至4月期间与诊断相关的计费数量以及特殊程序的支付情况。结果表明，与上一年相比，通过计算机辅助文档记录和编码，特殊程序中检测到并计费的与诊断相关的计费数量和支付数量显著增加。
