title: [Computer-assisted classification of ICD-9/10 and IKPM in compliance with the new federal health care regulation--practice-oriented solution for trauma surgery and orthopedics].
abstract: From the beginning of 1995, the German law on the health system structure prescribes that in all clinics the four-digit ICD code be supplied for each diagnosis and the ICPM code for each operation. This makes on-line access to diagnosis and therapy codes embedded in a clinic documentation system advisable. Since 1 February 1995, in one department of traumatologic surgery the ICD diagnosis and ICPM therapy coding is managed on-line by the doctors in the outpatient clinic and operation theatre, using the "do it" coding system in combination with the KAUZ system for clinic documentation. The user guidance supplied by a frequency-oriented menu and specialist traumatological terms makes it possible to determine the ICD and ICPM codes without any great expenditure of effort. Furthermore, the appropriate flat rates per case and special charges are displayed. Comparison of manual and computer-assisted coding of operations during 1 month (160 patients, 173 operations) showed that manual coding could be corrected or improved by the computerized system in 35% of cases. The ICD-10 system has already been integrated: it improves the recording of diagnoses and will simplify the change over to the coming new revision.
authors.affiliation: Orthopädische Universitätsklinik Homburg/Saar.
authors.forename: D
authors.initials: D
authors.lastname: Deimel
authors.forename: H J
authors.initials: HJ
authors.lastname: Hesselschwerdt
authors.forename: A
authors.initials: A
authors.lastname: Lusznat
mesh_terms: D001330:Electronic Data Processing; D005858:Germany; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000295:instrumentation*; D009862:Online Systems / Q000295:instrumentation*; D009985:Orthopedics; D012984:Software; D014947:Wounds and Injuries / Q000145:classification* / Q000601:surgery