Deimel D, Hesselschwerdt H J, Heisel J
Orthopädische Universitätsklinik Homburg/Saar.
Z Orthop Ihre Grenzgeb. 1997 Nov-Dec;135(6):528-34. doi: 10.1055/s-2008-1039740.
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.
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.
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%.
Because of its easy handling the coding system "do it" represents a good alternative to conventional coding rsp. clear text analysis.
通过在德国医疗系统中引入“Fallpauschalen”和“特殊费用”，诊断和治疗编码获得了新的动力。因此，提出了一种基于计算机的ICD和ICPM数字新编码系统。医生能够在其文档编制过程中进行简单有效的分类。
开发一个层次菜单系统，其第一部分代表解剖区域。第二部分保留用于其特殊解剖区域内最常见的诊断或治疗。通过进一步的子菜单，可以对骨科和创伤科领域的所有其他ICD编号进行编码（按频率选择）。自1995年1月1日起，该编码系统已投入临床使用。
对一年内1316例患者的1551次手术的该编码系统效率进行控制。使用ICD-10时，骨科创伤诊断的表示比ICD-9提高了1.8倍。根据ICPM，对3560种治疗进行了编码，平均每次手术有2至3项操作。发现21.9%存在“Fallpauschalen”，27.7%存在“特殊费用”。一年内编码错误率从25%降至5%。
由于其易于操作，“自己动手做”编码系统是传统编码或纯文本分析的一个很好的替代方案。
