[Diagnosis and procedure coding in relation to the DRG system].
BACKGROUND
The aim was to investigate the consequences of missing or wrong diagnoses and procedure codes in relation to the DRG system.


METHODS
All patients admitted to the orthopaedic department during the course of one week, 155 patients, were consecutively entered. Former diagnoses were registered from interviews with all the patients, former case notes, and present hospital records. They were then compared to the department case notes, including diagnosis and procedure codes. All codes were then compared in Visual DRG (version 97) for grouping.


RESULTS
The coding was correct in 103 of 155 cases (65%). In 52 cases (35%) the coding was incorrect or insufficient, in 18 of the 52 cases (12% overall) it lead to a decrease in the DRG value, which extrapolated on a yearly base, would lead to a loss of DDK 23 million. In total, coding was incorrect or insufficient in one third of the records.


CONCLUSIONS
Irrespective of whether the DRG system is implemented or not, it is important that departments register the correct diagnoses and procedures, not only those relevant to the department. There is a continued need to teach and inform the staff about the correct coding procedures.
Nymark
Tine
T
Ortopaedkirurgisk afdeling O, Odense Universitets-hospital, DK-5000 Odense C.
Thomsen
Karsten
K
Röck
Niels Dieter
ND
D039702:Current Procedural Terminology; D003718:Denmark; D003953:Diagnosis-Related Groups / Q000145:classification* / Q000191:economics / Q000592:standards; D003951:Diagnostic Errors / Q000191:economics; D005568:Forms and Records Control; D019983:Guideline Adherence; D006801:Humans; D007344:Insurance Claim Reporting / Q000145:classification*; D008499:Medical Records / Q000145:classification; D009985:Orthopedics / Q000191:economics* / Q000592:standards; D012042:Registries; D012051:Reimbursement Mechanisms; D013503:Surgery Department, Hospital / Q000191:economics* / Q000592:standards