Computerized pre-anesthetic evaluation results in additional abstracted comorbidity diagnoses.
OBJECTIVE
To study the impact of information from a physician-entry computerized preanesthetic evaluation system on the coding of International Classification of Diseases (ICD-9-CM) diagnoses and on hospital reimbursement due to alterations in diagnosis-related group (DRG) codes.


METHODS
Nonrandomized, unblinded trial conducted at a 570-bed university tertiary care hospital. First without and then with reference to information contained on computer-based preanesthetic evaluation reports, medical charts were coded by the study institution's usual professional codes for ICD-9-CM discharge diagnoses and DRG assignment.


RESULTS
For 22 of 180 charts studied (12%, 95% confidence limits 7.4% to 16.7%), at least one ICD-9-CM diagnosis was added. Three of 84 DRG-based reimbursements were altered, increasing hospital reimbursement by 1.5%.


CONCLUSIONS
Supplemental information from a physician-entered, problem-oriented, computerized preanesthetic evaluation system improved discovery of diagnoses in the population studied.
Gibby
G L
GL
Department of Anesthesiology, University of Florida, College of Medicine, Gainesville 32610-0254, USA.
Paulus
D A
DA
Sirota
D J
DJ
Treloar
R W
RW
Jackson
K I
KI
Gravenstein
J S
JS
van der Aa
J J
JJ
D000758:Anesthesia; D003201:Computers; D003365:Costs and Cost Analysis; D003953:Diagnosis-Related Groups; D005069:Evaluation Studies as Topic; D006801:Humans; D008501:Medical Records, Problem-Oriented; D011300:Preoperative Care; D012051:Reimbursement Mechanisms