Clinical Documentation for Intensivists: The Impact of Diagnosis Documentation.

OBJECTIVES: The aim of this review is to describe the interaction of clinical documentation with patient care, measures of patient acuity, quality metrics, research database accuracy, and healthcare reimbursement in order to highlight potential areas of improvement for intensivists. DATA SOURCES: An online search of PubMed was undertaken as well as review of resources published by the American Academy of Pediatrics, the Society of Critical Care Medicine, the American Medical Association, and the Association of Clinical Documentation Improvement Specialists. STUDY SELECTION: Selected publications included those that described coding, medical record documentation, healthcare reimbursement, quality metrics, administrative databases, Clinical Documentation Improvement programs, medical scribe programs, and various payment models. DATA EXTRACTION: Relevant information was extracted to highlight the impact of diagnosis documentation on patient care, perceived patient severity of illness, quality metrics, and healthcare reimbursement. Query data from our hospital's Clinical Documentation Improvement program were reviewed to highlight areas of improvement within our own Division of Critical Care Medicine. Additionally, interventions to improve clinical documentation were incorporated into this review. DATA SYNTHESIS: Available data in the literature indicate that documentation of precise diagnoses in the medical record has a positive impact on quality metrics, accuracy of administrative databases, hospital reimbursement, and perceived patient complexity. However, there is insufficient data to make conclusions regarding documentation of specific diagnoses and effects on patient care. Administrative responsibilities associated with documentation have been increasing, especially with the introduction of electronic medical records. CONCLUSIONS: Documentation of specific diagnoses in the medical record is important in the broad context of our existing medical system but there is an associated burden in doing so. Widespread implementation of electronic medical record systems has inadvertently led to clinician dissatisfaction and burnout. Research is needed to further evaluate the impact of documentation on patient care as well as steps to decrease the associated burden.

Sensitivity and Specificity of Administrative Medical Coding for Pediatric Eosinophilic Esophagitis.

OBJECTIVES: Eosinophilic esophagitis (EoE) is a delayed-type hypersensitivity with increasing rates among pediatric populations. Although studies have used International Classification of Diseases (ICD) coding to define local cohorts and report disease epidemiology, the accuracy of the EoE ICD code for pediatric EoE is unknown. METHODS: We searched the Intermountain Healthcare Database for pediatric cases with the EoE ICD code over a 5-year period. We cross-referenced these results with a recently published pediatric EoE cohort from the same region and period, where incident cases were identified via retrospective review of pathology reports and medical records. Using the retrospective review cohort as the reference standard, we evaluated the accuracy of the EoE ICD code. RESULTS: Via retrospective review, we identified 1129 new pediatric EoE cases in the Intermountain Healthcare system over 5 years. Six hundred ten of these had the EoE ICD code associated with their chart. Out of 878,872 unique pediatric records in the Intermountain Healthcare system, 219 had the EoE ICD code incorrectly applied. The specificity of the EoE ICD code in children was 99%, but sensitivity and positive predictive value were 61% and 79%, respectively. CONCLUSIONS: The EoE ICD code has strengths and weaknesses in pediatrics. The EoE ICD code is specific, with few false positives across a large population, but not sensitive. The low sensitivity is likely multifactorial and requires further evaluation. Compared to retrospective chart review, which allows for application of clinicopathologic EoE diagnostic criteria, sole use of ICD codes results in underascertainment of EoE cases and key misclassifications.

Assessment of ICD-10-CM code assignment validity for case finding of outpatient anticoagulant-related bleeding among Medicare beneficiaries.

PURPOSE: To assess performance of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code assignments for identifying bleeding events resulting in emergency department visits and hospitalizations among outpatient Medicare beneficiaries prescribed anticoagulants. METHODS: Performance of 206 ICD-10-CM code assignments indicative of bleeding, five anticoagulant adverse effect/poisoning codes, and five coagulopathy codes (according to Medicare Parts A and B claims) as assessed among Medicare fee-for-service beneficiaries prescribed anticoagulants between October 1, 2015 and September 30, 2016 (according to Part D claims). Structured medical record review was the gold standard for validating the presence of anticoagulant-related bleeding. Sensitivity was adjusted to correct for partial verification bias due to sampling design. RESULTS: Based on the study sample of 1166 records (583 cases, 583 controls), 57 of 206 codes yielded the optimal performance for anticoagulant-related bleeding (diagnostic odds ratio, 51; positive predictive value (PPV), 75.7% [95% CI, 72.0%-79.1%]; adjusted sensitivity, 70.0% [95% CI, 63.2%-77.7%]). Codes for intracranial bleeding demonstrated the highest PPV (85.0%) and adjusted sensitivity (91.0%). Bleeding codes in the primary position demonstrated high PPV (86.9%), but low adjusted sensitivity (36.0%). The adjusted sensitivity improved to 69.5% when codes in a secondary position were added. Only one adverse effect/poisoning code was used, appearing in 7.8% of cases and controls (PPV, 71.4% and adjusted sensitivity, 6.8%). CONCLUSIONS: Performance of ICD-10-CM code assignments for bleeding among patients prescribed anticoagulants varied by bleed type and code position. Adverse effect/poisoning codes were not commonly used and would have missed over 90% of anticoagulant-related bleeding cases.

Validity of ICD-9 and ICD-10 codes used to identify acute liver injury: A study in three European data sources.

PURPOSE: Validating cases of acute liver injury (ALI) in health care data sources is challenging. Previous validation studies reported low positive predictive values (PPVs). METHODS: Case validation was undertaken in a study conducted from 2009 to 2014 assessing the risk of ALI in antidepressants users in databases in Spain (EpiChron and SIDIAP) and the Danish National Health Registers. Three ALI definitions were evaluated: primary (specific hospital discharge codes), secondary (specific and nonspecific hospital discharge codes), and tertiary (specific and nonspecific hospital and outpatient codes). The validation included review of patient profiles (EpiChron and SIDIAP) and of clinical data from medical records (EpiChron and Denmark). ALI cases were confirmed when liver enzyme values met a definition by an international working group. RESULTS: Overall PPVs (95% CIs) for the study ALI definitions were, for the primary ALI definition, 84% (60%-97%) (EpiChron), 60% (26%-88%) (SIDIAP), and 74% (60%-85%) (Denmark); for the secondary ALI definition, 65% (45%-81%) (EpiChron), 40% (19%-64%) (SIDIAP), and 70% (64%-77%) (Denmark); and for the tertiary ALI definition, 25% (18%-34%) (EpiChron), 8% (7%-9%) (SIDIAP), and 47% (42%-52%) (Denmark). The overall PPVs were higher for specific than for nonspecific codes and for hospital discharge than for outpatient codes. The nonspecific code "unspecified jaundice" had high PPVs in Denmark. CONCLUSIONS: PPVs obtained apply to patients using antidepressants without preexisting liver disease or ALI risk factors. To maximize validity, studies on ALI should prioritize hospital specific discharge codes and should include hospital codes for unspecified jaundice. Case validation is required when ALI outpatient cases are considered.

Identification of gastrointestinal perforation based on ICD-10 code in a Japanese administrative medical information database and associated drug exposure risk factors.

PURPOSE: The purpose of this study is to evaluate the accuracy of gastrointestinal (GI) perforation ICD-10 coding in the Diagnosis Procedure Combination (DPC) database and to examine drug exposure risk factors for GI perforation. METHODS: A total of 100 patients with GI perforation ICD-10 codes were selected randomly from Kagawa University Hospital's DPC database between April 2011 and December 2016. Two experienced specialist physicians independently reviewed the medical records and classified cases as "definite A," "definite B," "probable," or "no GI perforation." The positive predictive values (PPVs) of "definite A/B" cases were calculated after stratification by sex, age, ICD-10 code, and diagnostic information in the DPC data. The number of prescribed drugs with side effects of GI perforation according to historical data was compared between "definite A/B" and "no GI perforation" cases. RESULTS: The overall PPV was 47.0% (95% confidence interval [CI], 36.9-57.2). However, the PPVs for the three categories of diagnostic information in the DPC data ("main diagnosis," "diagnosis causing admission," and "most resource-intensive diagnosis") were each more than 70% after excluding inappropriate patients. Additionally, the PPV focused on these three categories was 76.3% (95% CI, 59.8-88.6). Prescribed drugs with side effects of GI perforation were more frequently detected in "definite A/B" cases (P = .028). CONCLUSIONS: Although the overall PPV for GI perforation based on ICD-10 code was low, our results suggest that the PPV could be improved by appropriate selection of DPC diagnosis category and that use of multiple medications enhances the risk of GI perforation.

[Determinants of time required by medical information technicians for quality control of hospital activity coding, in French medico-administrative system]. / Déterminants du temps nécessaire au contrôle qualité dans le cadre du programme de médicalisation des systèmes d'information (PMSI), dans le champ médecine, chirurgie et obstétrique (MCO) d'un centre hospitalier régional, par les techniciens d'information médicale.

BACKGROUND: Since 2008, in France, hospital funding is determined by the nature of activities provided (activity-based funding). Quality control of hospital activity coding is essential to optimize hospital remuneration. There is a need for reliable tools to allocate human resources wisely in order to improve these controls. METHODS: The main objective of this study was to identify the determinants of time needed by medical information technicians to control hospital activity coding in a Regional Hospital Center. From March 2016 to the beginning of January 2017, medical information technicians reported the time they spent on each quality control, and the time they needed when they had to code the entire stay. Multiple linear regressions were performed to identify the determinants of quality control or coding duration. A split sample validation was used: model was created on one half of the sample and validated on the remaining half. RESULTS: Among the controls, 5431 were included in the analysis of determinants of control duration (2715 kept aside for model validation). Seven determinants have been identified (stay duration, level of complexity, month of control, type of control, medical information technician, rank of classing information, and major diagnostic category). The correlation coefficient between predicted and real control duration was 0.71 (P<10-4); 808 stays were included in the analysis of determinants of coding duration (404 kept aside for model validation). Two determinants have been identified. The correlation coefficient, between predicted and real coding duration, was 0.47 (P<10-3). We performed the same multiple regression, on 2017 activity data, to estimate the weight of each hospital activity pole, regarding quality control of hospital activity coding. CONCLUSION: We succeeded in modeling time needed for quality control of hospital stays. These results helped to estimate human resources required for quality control of each hospital pole. Nevertheless, the second analysis did not give satisfactory results: we failed in modeling time needed to code hospital stays.

A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin.

INTRODUCTION: Clinical documentation is the key determinant of inpatient acuity of illness and payer reimbursement. Every inpatient hospitalization is placed into a diagnosis related group with a relative value based on documented procedures, conditions, comorbidities and complications. The Case Mix Index (CMI) is an average of these diagnosis related groups and directly impacts physician profiling, medical center profiling, reimbursement, and quality reporting. We hypothesize that a focused, physician-led initiative to improve clinical documentation of vascular surgery inpatients results in increased CMI and contribution margin. METHODS: A physician-led coding initiative to educate physicians on the documentation of comorbidities and conditions was initiated with concurrent chart review sessions with coding specialists for 3 months, and then as needed, after the creation of a vascular surgery documentation guide. Clinical documentation and billing for all carotid endarterectomy (CEA) and open infrainguinal procedures (OIPs) performed between January 2013 and July 2016 were stratified into precoding and postcoding initiative groups. Age, duration of stay, direct costs, actual reimbursements, contribution margin (CM), CMI, rate of complication or comorbidity, major complication or comorbidity, severity of illness, and risk of mortality assigned to each discharge were abstracted. Data were compared over time by standardizing Centers for Medicare and Medicaid Services (CMS) values for each diagnosis related group and using a CMS base rate reimbursement. RESULTS: Among 458 CEA admissions, postcoding initiative CEA patients (n = 253) had a significantly higher CMI (1.36 vs 1.25; P = .03), CM ($7859 vs $6650; P = .048), and CMS base rate reimbursement ($8955 vs $8258; P = .03) than precoding initiative CEA patients (n = 205). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (43% vs 27%; P < .01). Among 504 OIPs, postcoding initiative patients (n = 227) had a significantly higher CMI (2.23 vs 2.05; P < .01), actual reimbursement ($23,203 vs $19,909; P < .01), CM ($12,165 vs $8840; P < .01), and CMS base rate reimbursement ($14,649 vs $13,496; P < .01) than precoding initiative patients (n = 277). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (61% vs 43%; P < .01). For both CEA and OIPs, there were no differences in age, duration of stay, total direct costs, or primary insurance status between the precoding and postcoding patient groups. CONCLUSIONS: Accurate and detailed clinical documentation is required for key stakeholders to characterize the acuity of inpatient admissions and ensure appropriate reimbursement; it is also a key component of risk-adjustment methods for assessing quality of care. A physician-led documentation initiative significantly increased CMI and CM.

Case-Mix for Performance Management: A Risk Algorithm Based on ICD-10-CM.

BACKGROUND: Accurate risk adjustment is the key to a reliable comparison of cost and quality performance among providers and hospitals. However, the existing case-mix algorithms based on age, sex, and diagnoses can only explain up to 50% of the cost variation. More accurate risk adjustment is desired for provider performance assessment and improvement. OBJECTIVE: To develop a case-mix algorithm that hospitals and payers can use to measure and compare cost and quality performance of their providers. METHODS: All 6,048,895 patients with valid diagnoses and cost recorded in the US Veterans health care system in fiscal year 2016 were included in this study. The dependent variable was total cost at the patient level, and the explanatory variables were age, sex, and comorbidities represented by 762 clinically homogeneous groups, which were created by expanding the 283 categories from Clinical Classifications Software based on ICD-10-CM codes. The split-sample method was used to assess model overfitting and coefficient stability. The predictive power of the algorithms was ascertained by comparing the R, mean absolute percentage error, root mean square error, predictive ratios, and c-statistics. RESULTS: The expansion of the Clinical Classifications Software categories resulted in higher predictive power. The R reached 0.72 and 0.52 for the transformed and raw scale cost, respectively. CONCLUSIONS: The case-mix algorithm we developed based on age, sex, and diagnoses outperformed the existing case-mix models reported in the literature. The method developed in this study can be used by other health systems to produce tailored risk models for their specific purpose.

Reliability measurement and ICD-10 validation of ICPC-2 for coding/classification of diagnoses/health problems in an African primary care setting.

Background: The routine application of a primary care classification system to patients' medical records in general practice/primary care is rare in the African region. Reliable data are crucial to understanding the domain of primary care in Nigeria, and this may be actualized through the use of a locally validated primary care classification system such as the International Classification of Primary Care, 2nd edition (ICPC-2). Although a few studies from Europe and Australia have reported that ICPC is a reliable and feasible tool for classifying data in primary care, the reliability and validity of the revised version (ICPC-2) is yet to be objectively determined particularly in Africa. Objectives: (i) To determine the convergent validity of ICPC-2 diagnoses codes when correlated with International Statistical Classification of Diseases (ICD)-10 codes, (ii) to determine the inter-coder reliability among local and foreign ICPC-2 experts and (iii) to ascertain the level of accuracy when ICPC-2 is engaged by coders without previous training. Methods: Psychometric analysis was carried out on ICPC-2 and ICD-10 coded data that were generated from physicians' diagnoses, which were randomly selected from general outpatients' clinic attendance registers, using a systematic sampling technique. Participants comprised two groups of coders (ICPC-2 coders and ICD-10 coders) who coded independently a total of 220 diagnoses/health problems with ICPC-2 and/or ICD-10, respectively. Results: Two hundred and twenty diagnoses/health problems were considered and were found to cut across all 17 chapters of the ICPC-2. The dataset revealed a strong positive correlation between selected ICPC-2 codes and ICD-10 codes (r ≈ 0.7) at a sensitivity of 86.8%. Mean percentage agreement among the ICPC-2 coders was 97.9% at the chapter level and 95.6% at the rubric level. Similarly, Cohen's kappa coefficients were very good (κ > 0.81) and were higher at chapter level (0.94-0.97) than rubric level (0.90-0.93) between sets of pairs of ICPC-2 coders. An accuracy of 74.5% was achieved by ICD-10 coders who had no previous experience or prior training on ICPC-2 usage. Conclusion: Findings support the utility of ICPC-2 as a valid and reliable coding tool that may be adopted for routine data collection in the African primary care context. The level of accuracy achieved without training lends credence to the proposition that it is a simple-to-use classification and may be a useful starting point in a setting devoid of any primary care classification system for morbidity and mortality registration at such a critical level of public health importance.

Validation of the All Patient Refined Diagnosis Related Group (APR-DRG) Risk of Mortality and Severity of Illness Modifiers as a Measure of Perioperative Risk.

The All Patient Refined Diagnosis Related Group (APR-DRG) is an inpatient visit classification system that assigns a diagnostic related group, a Risk of Mortality (ROM) subclass and a Severity of Illness (SOI) subclass. While extensively used for cost adjustment, no study has compared the APR-DRG subclass modifiers to the popular Charlson Comorbidity Index as a measure of comorbidity severity in models for perioperative in-hospital mortality. In this study we attempt to validate the use of these subclasses to predict mortality in a cohort of surgical patients. We analyzed all adult (age over 18 years) inpatient non-cardiac surgery at our institution between December 2005 and July 2013. After exclusions, we split the cohort into training and validation sets. We created prediction models of inpatient mortality using the Charlson Comorbidity Index, ROM only, SOI only, and ROM with SOI. Models were compared by receiver-operator characteristic (ROC) curve, area under the ROC curve (AUC), and Brier score. After exclusions, we analyzed 63,681 patient-visits. Overall in-hospital mortality was 1.3%. The median number of ICD-9-CM diagnosis codes was 6 (Q1-Q3 4-10). The median Charlson Comorbidity Index was 0 (Q1-Q3 0-2). When the model was applied to the validation set, the c-statistic for Charlson was 0.865, c-statistic for ROM was 0.975, and for ROM and SOI combined the c-statistic was 0.977. The scaled Brier score for Charlson was 0.044, Brier for ROM only was 0.230, and Brier for ROM and SOI was 0.257. The APR-DRG ROM or SOI subclasses are better predictors than the Charlson Comorbidity Index of in-hospital mortality among surgical patients.

Application of case mix index in the allocation of nursing human resources.

AIM: To investigate the feasibility of the case mix index and compare the allocation of nursing human resources between two departments of a hospital with different case mix indexes in China. BACKGROUND: The case mix index is used to assess the resource allocation of all cases in two departments of a hospital. Its values can determine the resource allocation required to diagnose and treat the patients. METHODS: Clinical data were obtained from 23 different departments in 2015 and analysed retrospectively from October to November, 2016. Factors influencing the allocation of registered nurses were identified, and balanced quantities of patients with different case mix indexes were chosen from two departments. Spearman correlation analysis was performed. RESULTS: The per capita nursing workload was significant (r = .669, p = .000). The length of hospital stay, quantity of nurses, and department case mix index were correlated with the nursing workload (t = 4.211, p = .000; t = 2.962, p = .008; t = 2.266, p = .035). Education levels (Z = -1.391, p = .164) and the professional titles (Z = -1.832, p = .067) of the nurses were not statistically significant, whereas the registered nurse level differed between two departments (Z = -2.125, p = .034). CONCLUSION: The case management index provides references for the efficient allocation of registered nurses in clinical practice.

Impact of Cross-level Measurement Noninvariance on Hospital Rankings Based on Patient Experiences With Care in 7 European Countries.

BACKGROUND: Hospital-level findings on patient experiences with care are increasingly reported publicly. A critical aspect left unexamined is the commonality of composite measures of patient experiences across different groups of patients, nursing units, hospitals, and countries. Absence of commonality is termed measurement noninvariance and is hypothesized to have a strong impact on performance assessment. AIM: The aim of this study is to examine measurement invariance across groups and levels under study (patients, nursing units, hospitals, and countries) and illustrate the degree to which this method of analysis impacts hospital rankings. RESEARCH DESIGN: Data were collected from 11,289 patients in 7 European countries, 186 hospitals, and 824 nursing units. Multilevel factor analytic models were applied to evaluate measurement invariance across the hierarchical levels of the study and across groups at specific levels (self-perceived health at patient level; unit speciality at nursing unit level). Hospital rankings for the final multilevel model were compared with those from a single-level factor model that is unsuspecting of measurement invariance. RESULTS: Cross-group invariance was shown for levels of self-perceived health and to a large degree also for nursing unit speciality. Patient experience composite measures were, however, not invariant across patient, unit, and hospital levels. Hospital rankings were largely impacted when accounted for this cross-level invariance. The percentage of hospitals with discordant ranks by >10 percentile points varied from 26.7% in Spain to 70% in Poland. CONCLUSIONS: Leaving unexamined possible noninvariance across groups and hierarchical levels may have far reaching consequences for how the public perceives hospitals' position relative to other hospitals.

Differences in Impact of Definitional Elements on Mortality Precludes International Comparisons of Sepsis Epidemiology-A Cohort Study Illustrating the Need for Standardized Reporting.

OBJECTIVES: Sepsis generates significant global acute illness burden. The international variations in sepsis epidemiology (illness burden) have implications for region specific health policy. We hypothesised that there have been changes over time in the sepsis definitional elements (infection and organ dysfunction), and these may have impacted on hospital mortality. DESIGN: Cohort study. SETTING: We evaluated a high quality, nationally representative, clinical ICU database including data from 181 adult ICUs in England. PATIENTS: Nine hundred sixty-seven thousand five hundred thirty-two consecutive adult ICU admissions from January 2000 to December 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: To address the proposed hypothesis, we evaluated a high quality, nationally representative, clinical, ICU database of 967,532 consecutive admissions to 181 adult ICUs in England, from January 2000 to December 2012, to identify sepsis cases in a robust and reproducible way. Multinomial logistic regression was used to report unadjusted trends in sepsis definitional elements and in mortality risk categories based on organ dysfunction combinations. We generated logistic regression models and assessed statistical interactions with acute hospital mortality as outcome and cohort characteristics, sepsis definitional elements, and mortality risk categories as covariates. Finally, we calculated postestimation statistics to illustrate the magnitude of clinically meaningful improvements in sepsis outcomes over the study period. Over the study period, there were 248,864 sepsis admissions (25.7%). Sepsis mortality varied by infection sources (19.1% for genitourinary to 43.0% for respiratory; p < 0.001), by number of organ dysfunctions (18.5% for 1 to 69.9% for 5; p < 0.001), and organ dysfunction combinations (18.5% for risk category 1 to 58.0% for risk category 4). The rate of improvement in adjusted hospital mortality was significant (odds ratio, 0.939 [0.934-0.945] per year; p < 0.001), but showed different secular trends in improvement between infection sources. CONCLUSIONS: Within a sepsis cohort, we illustrate case-mix heterogeneity using definitional elements (infection source and organ dysfunction). In the context of improving outcomes, we illustrate differential secular trends in impact of these variables on adjusted mortality and propose this as a valid reason for international variations in sepsis epidemiology. Our article highlights the need to determine standardized reporting elements for optimal comparisons of international sepsis epidemiology.

[Consistency and Reliability of MDK Expertise Examining the Encoding in the German DRG System]. / Einheitlichkeit der richtlinienkonformen Begutachtung durch den Medizinischen Dienst der Krankenversicherung bei der Prüfung der Kodierung im G-DRG-System.

INTRODUCTION: Hospital inpatient stays are reimbursed on the basis of German diagnosis-related groups (G-DRG). The G-DRG classification system is based on complex coding guidelines. The Medical Review Board of the Statutory Health Insurance Funds (MDK) examines the encoding by hospitals and delivers individual expertises on behalf of the German statutory health insurance companies in cases in which irregularities are suspected. A study was conducted on the inter-rater reliability of the MDK expertises regarding the scope of the assessment. METHODS: A representative sample of 212 MDK expertises was taken from a selected pool of 1 392 MDK expertises in May 2013. This representative sample underwent a double-examination by 2 independent MDK experts using a special software based on the 3MTM G-DRG Grouper 2013 of 3M Medica, Germany. The following items encoded by the hospitals were examined: DRG, principal diagnosis, secondary diagnoses, procedures and additional payments. It was analysed whether the results of MDK expertises were consistent, reliable and correct. RESULTS: 202 expertises were eligible for evaluation, containing a total of 254 questions regarding one or more of the 5 items encoded by hospitals. The double-examination by 2 independent MDK experts showed matching results in 187 questions (73.6%) meaning they had been examined consistently and correctly. 59 questions (23.2%) did not show matching results, nevertheless they had been examined correctly regarding the scope of the assessment. None of the principal diagnoses was significantly affected by inconsistent or wrong judgment. CONCLUSION: A representative sample of MDK expertises examining the DRG encoding by hospitals showed a very high percentage of correct examination by the MDK experts. Identical MDK expertises cannot be achieved in all cases due to the scope of the assessment. Further improvement and simplification of codes and coding guidelines are required to reduce the scope of assessment with regard to correct DRG encoding and its examination.

Introducing the reporting system for thyroid fine-needle aspiration cytology according to the new guidelines of the Japan Thyroid Association.

The Japan Thyroid Association (JTA) recently published new guidelines for clinical management of thyroid nodules. This paper introduces their diagnostic system for reporting thyroid fine-needle aspiration cytology. There are two points where the new reporting system that differs from existing internationally-accepted ones. The first is the subclassification of the so-called indeterminate category, which is divided into 'follicular neoplasm' and 'others'. The second is the subclassification of follicular neoplasm into 'favor benign', 'borderline' and 'favor malignant'. It is characterized by self-explanatory terminologies as to histological type and probability of malignancy to establish further risk stratification as well as to facilitate communication between clinicians and cytopathologists. The different treatment strategies adopted for thyroid nodules is deeply influenced by the particular diagnostic system used for thyroid cytology. In Western countries all patients with follicular neoplasms are advised to have immediate diagnostic surgery while patients in Japan often undergo further risk stratification without immediate surgery. The JTA diagnostic system of reporting thyroid cytology is designed for further risk stratification of patients with indeterminate cytology. If a surgeon applies diagnostic lobectomy to all patients with follicular neoplasm unselectively, this subclassification of follicular neoplasm has no practical meaning and is unnecessary. Cytological risk stratification of follicular neoplasms is optional and cytopathologists can choose either a simple 6-tier system without stratification of follicular neoplasm or a complicated 8-tier system depending on their experience in thyroid cytology and clinical management.

[Analysis of ambulatory coding quality in Saxony and Thuringia using AOK PLUS billing data - utilisation of the qualifying character "Z" in the documentation of diagnoses]. / Analyse der ambulanten Kodierqualität in Sachsen und Thüringen anhand von Leistungsdaten der AOK PLUS - die Verwendung des Zusatzkennzeichens "Z" in der Diagnosedokumentation.

As a part of the health care reform 2007 the German risk structure compensation scheme was extended so as to connect the financial cash flow towards the payers to morbidity information from ambulatory care. Within this context, morbidity information consists of prescriptions as well as coded ambulatory diagnoses. Accordingly, a high quality of coding is essential for a morbidity compatible allocation of funds. The aim of this study was to evaluate coding quality via qualifying characters as well as to identify future challenges. It focuses on diagnoses which are qualified as "assured" or "post-treatment" from about 350 million diagnoses of about 11 k practitioners' treatment of 2.7 million AOK PLUS insurants in Saxony and Thuringia during the years 2007-2010. The practitioners' documented diagnoses were aggregated within several groups according to the code of specialisation which is attached to the practitioner's 9-digit lifelong identification number (LANR). As a result, the number of "assured" diagnoses generally rose from year to year. Furthermore, diagnoses marked as "assumption" or "exclusion" remain constant over time. We identified a lack of diagnosis coding precision regarding the condition after certain medical events. In particular, general practitioners tend to use diagnosis codes qualified as "post-treatment" instead of using correct "assured" diagnoses qualified for conditions after certain events. Consequently, we expect adverse effects evaluating the cost of diseases as only "assured" diagnoses are considered within the risk transfer compensation scheme.

DRG benchmarking: analysis of service structures and -differences in dermatology departments.

BACKGROUND: In the context of DRG-based hospital funding, the analysis of services provided in dermatologic inpatient care is highly relevant. We analyzed and compared clinical service structures and varieties in dermatologic hospitals through a benchmarking technique. METHODS: For this multicenter cross-sectional study, routine data from 46 German dermatologic clinics and departments were collected, processed, and analyzed. In total, 95 257 data sets from 2011 were available. The data were grouped according to the G-DRG-system 2013 version. RESULTS: The average length of stay for all cases was 6.3 days (DRG "inliers": 5.7 days), and average patient age was 52 years. In total, 55 % of all cases were grouped to medical, 45 % to surgical DRGs. 71 % of all hospitals provide services within or close to this average value (± 10 %). No association was found between the number of hospital beds and the variety of clinical services provided in our sample. We found huge varieties in several parameters assessing the coding quality. CONCLUSIONS: The results reflect the heterogeneous reality in German inpatient dermatology. The varieties in dermatologic service range still depend on patient-related factors as well as infrastructural conditions and the resources available at each site.

Is there any purpose in classifying subtrochanteric fractures? The reproducibility of four classification systems.

INTRODUCTION: Classification systems are used for communication, planning treatment options, predicting outcomes and research purposes. The majority of subtrochanteric fractures are now treated with intramedullary nails and therefore questioning the need for classification. OBJECTIVES: To assess the intra- and inter-observer reproducibility of the Seinsheimer, AO and Russell-Taylor (RT) classification systems and to assess a new simple system (MCG). MATERIALS AND METHODS: The MCG system was developed to alert the surgeon to potential hazards: type 1-subtrochanteric fracture (ST#) with intact trochanters, type 2-ST# involving greater trochanter (entry point for nailing difficult), and type 3-ST# involving lesser trochanter (most unstable). Thirty-two anteroposterior and lateral radiographs of subtrochanteric fractures were classified independently for each of the 4 classification systems by 4 observers on 2 separate occasions. RESULTS: The intra- and inter-observer variation was poor in all systems (highest Kappa 0.35). MCG had the best reproducibility followed by RT, then AO and Seinsheimer. The data were re-analysed to determine whether the findings were due to the presence of too many subgroups and whether the observers could more accurately identify important individual subclassifications: Seinsheimer 3a, AO31-A3.1, RT 1 or 2, RT a or b, and MCG3. The MCG3 had the narrowest ranges for intra- and inter-observer reproducibility. CONCLUSIONS: The classification systems analysed in this study have poor reproducibility and seem to be of little value in predicting the outcome of intramedullary nailing as all of the fractures achieved union. The MCG system may be of some use in alerting the surgeon to potential problems.

Classification criteria for Sjogren's syndrome: we actually need to definitively resolve the long debate on the issue.

A new approach for the classification of patients with Sjögren's syndrome (SS) has been recently proposed. Although these new criteria substantially differ from the American European Consensus Group criteria, which have represented the gold standard for the last decade, when compared with each other the two sets show a high statistical degree of agreement. However, the fact that two different criteria to classify patient with SS could be available may introduce some additional difficulties in the scientific communication, making cohorts of patients selected by using different methods less than completely equivalent, and the results of epidemiological studies and therapeutic trials not entirely comparable. Consequently, to reach a consensus agreement on universally accepted classification criteria for SS seems to be a very desirable objective.