[Knowledge assessment of the coding using CSARR nomenclature, two years after its establishment]

Area of Science:

• Healthcare Informatics
• Rehabilitation Medicine
• Health Services Research

Context:

• French post-acute care and rehabilitation facilities utilize the Program for Medicalization of Information Systems (PMSI) to code activities.
• A specific catalogue of rehabilitation procedures, the CSARR, was implemented in 2013 to standardize coding.
• This study evaluates the CSARR's coherence in coding rehabilitation acts two years post-implementation.

Purpose:

• To assess the coherence and accuracy of rehabilitation act coding using the CSARR nomenclature within the French PMSI database.
• To analyze coding patterns related to patient numbers, therapist types, and therapist numbers.
• To identify potential areas for improvement in the CSARR system and therapist training.

Summary:

• Analysis of 72 million rehabilitation acts in 2015 revealed high utilization of the CSARR nomenclature, with 86% being individual acts.
• Physiotherapists and nurses were the primary coders.
• Identified coding errors included incorrect patient counts for individual and group acts, and underrepresentation of multiple therapists for complex rehabilitation.

Impact:

• The study indicates a generally good appropriation of CSARR coding rules by healthcare facilities.
• Findings suggest that simplifying the CSARR catalogue and providing additional therapist training could significantly enhance the quality of rehabilitation data.
• This research provides valuable insights for improving health information systems in rehabilitation settings.