[Simple and valid ICD9-/10- and IKPM coding using an electronic data-assisted coding system "do it"--experiences after one years use].

UNLABELLED

Question by introducing "Fallpauschalen" and "Sonderentgelte" in German health system the coding of diagnoses and therapies gains a new momentum. Therefore, a new computer based coding-system for ICD- and ICPM- digits is presented. The physician gets enabled for simple and valid classification within his documentation routine.

METHODS

Development of a hierarchic menue system, whose first part represents the anatomic region. The second part is reserved for the most common diagnosis rsp. therapies within its special anatomic region. By further sub-menues all other ICD numbers in the orthopedic and traumatologic field may be coded (selection related by frequency). This coding-system has been in clinical use since jan. 1st. 1995.

RESULTS

Control of the efficiency of this coding-systems by 1316 patients with 1551 operations within one year. By using ICD-10, the representation of orthopedic-traumatologic diagnosis inhanced by factor 1.8 versus ICD-9. According to ICPM, 3560 therapies were coded, making it 2-3 actions per operation. "Fallpauschalen" were found in 21.9%, in 27.7% there were "Sonderentgelte". Within one year the coding error rate was reduced from 25% to 5%.

CONCLUSIONS

Because of its easy handling the coding system "do it" represents a good alternative to conventional coding rsp. clear text analysis.