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[Consistency and Reliability of MDK Expertise Examining the Encoding in the German DRG System]
T Gaertner1, F Lehr2, B Blum3
1Medizinischer Dienst der Krankenversicherung in Hessen, Stabs- und Servicebereich Wissen und Kommunikation, Oberursel.
Gesundheitswesen (Bundesverband Der Arzte Des Offentlichen Gesundheitsdienstes (Germany))
|March 12, 2015
Summary
Medical Review Board (MDK) experts correctly examined hospital DRG coding in 73.6% of cases. While inconsistencies occurred, principal diagnoses were unaffected, highlighting a need for clearer coding guidelines.
Area of Science:
- Health Services Research
- Medical Informatics
- Healthcare Management
Background:
- Hospital inpatient stays are reimbursed using the German diagnosis-related groups (G-DRG) system.
- Complex coding guidelines underpin the G-DRG classification.
- The Medical Review Board of the Statutory Health Insurance Funds (MDK) audits hospital coding for irregularities.
Purpose of the Study:
- To assess the inter-rater reliability of MDK expert assessments on G-DRG encoded data.
- To evaluate the consistency, reliability, and correctness of MDK expert examinations of hospital coding.
Main Methods:
- A representative sample of 212 MDK expertises was selected from 1,392.
- Two independent MDK experts re-examined the sample using 3MTM G-DRG Grouper 2013 software.
- Key encoded items analyzed included DRG, principal and secondary diagnoses, procedures, and additional payments.
Main Results:
- Of 202 eligible expertises (254 questions), 73.6% showed matching results between the two MDK experts.
- 23.2% of questions had non-matching results but were correctly assessed regarding the scope.
- No principal diagnoses were significantly impacted by inconsistent or incorrect MDK judgments.
Conclusions:
- MDK expert examinations of hospital DRG encoding demonstrate a high degree of correctness.
- Achieving identical expertises in all cases is challenging due to assessment scope.
- Simplification of G-DRG codes and coding guidelines is recommended to improve accuracy and consistency.
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