Ryu S Y, Park J K, Suh I, Jee S H, Park J, Kim C B, Kim K S
Department of Preventive Medicine, College of Medicine, Chosun University, Kwangju, Korea.
Yonsei Med J. 2000 Oct;41(5):570-6. doi: 10.3349/ymj.2000.41.5.570.
We attempted to assess the accuracy of the International Classification of Diseases (ICD) codes for myocardial infarction (MI) in medical insurance claims, and to investigate the reasons for any inaccuracy. This study was designed as a preliminary study to establish a surveillance system for cardiovascular diseases in Korea. A sample of 258 male patients who were diagnosed with MI from 1993 to 1997 was selected from the Korea Medical Insurance Corporation cohort (KMIC cohort: 183,461 people). The registered medical record administrators were trained in the survey technique, and gathered data by investigating the medical records of the study subjects from March 1999 to May 1999. The definition of MI for this study included symptoms pursuant to the diagnostic criteria of chest pain, electrocardiogram (ECG) findings, cardiac enzyme and results of coronary angiography or nuclear scan. We asked the record administrators for the reasons of incorrectness for cases where the final diagnosis was 'not MI'. The accuracy rate of the ICD codes for MI in medical insurance claims was 76.0% (196 cases) of the study sample, and 3.9% (ten cases) of the medical records were not available due to hospital closures, non-computerization or missing information. Nineteen cases (7.4%) were classified as insufficient due to insufficient records of chest pain, ECG findings, or cardiac enzymes. The major reason of inaccuracy in the disease code for MI in medical insurance claims was 'to meet the review criteria of medical insurance benefits (45.5%)'. The department responsible for the inaccuracy was the department of inspection for medical insurance benefit of the hospitals.
我们试图评估医疗保险理赔中用于心肌梗死（MI）的国际疾病分类（ICD）编码的准确性，并调查任何不准确的原因。本研究被设计为一项初步研究，旨在建立韩国心血管疾病监测系统。从韩国医疗保险公社队列（KMIC队列：183,461人）中选取了258名在1993年至1997年期间被诊断为心肌梗死的男性患者作为样本。注册的病历管理人员接受了调查技术培训，并在1999年3月至1999年5月期间通过调查研究对象的病历收集数据。本研究中MI的定义包括依据胸痛诊断标准的症状、心电图（ECG）检查结果、心肌酶以及冠状动脉造影或核扫描结果。对于最终诊断为“非MI”的病例，我们询问了病历管理人员诊断错误的原因。医疗保险理赔中MI的ICD编码准确率为研究样本的76.0%（196例），3.9%（10例）的病历因医院关闭、未实现计算机化或信息缺失而无法获取。19例（7.4%）因胸痛、ECG检查结果或心肌酶记录不充分而被归类为不充分。医疗保险理赔中MI疾病编码不准确的主要原因是“为符合医疗保险福利审查标准（45.5%）”。负责不准确情况的部门是医院的医疗保险福利检查部门。
