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J Health Info Stat > Volume 40(3); 2015 > Article
J Health Info Stat 2015;40(3):161-175.
코딩시뮬레이션을 이용한 의사 및 심사간호사와 의무기록사의 질병코딩 차이 연구
배순옥 , 강길원 , 부유경 , 이영 , 최해선 , 최혜영
Original Article : A Study on the Difference in Disease Coding of Doctors, Medical Insurance Review Nurses and Medical Record Administrators based on Coding Simulation
Soon Ok Bae , Gil Won Kang , Yoo Kyung Boo , Young Lee , Hae Sun Choi , Hye Young Choi
ctive of this study is to investigate the difference in disease coding of doctors, medical insurance review nurses and medical record administrators who are directly involved in disease coding in hospital.
Thirteen virtual medical records were developed for common diseases. The study subjects were requested to select principal diagnosis and other diagnoses for the each record. The survey was conducted through web pages specially developed for coding simulation. 29 doctors, 74 medical insurance review nurses, and 100 medical record administrators participated in this survey.
There was large difference in the concordance rate between the study subjects’ answer and coding guidelines published by the National Statistical Office. Concordance rate was high in medical record administrators (93.6%) but low in doctors (43.1%) and medical insurance review nurses (35.6%). The difference was noticeable in the way of using Z codes as principal diagnosis. Also large difference existed in the way of coding symptom under treatment and underlying disease.
This study shows that there are large differences in disease coding depending on the occupation. To decrease this difference, it is needed to refine the coding guidelines and strengthen the education about them.
Key words: Korean classification of diseases, Difference in disease coding, Doctor, Health insurance review nurses, Medical record administrator
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