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Computerized pre-anesthetic evaluation results in additional abstracted comorbidity diagnoses
G L Gibby1, D A Paulus, D J Sirota
1Department of Anesthesiology, University of Florida, College of Medicine, Gainesville 32610-0254, USA.
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.