基于国家医疗保障疾病诊断相关分组支付视角的肿瘤手术病例严重并发症或合并症漏编现状与经济损益分析OA

Objective To investigate the current status of under-coding of major complications or comorbidities(MCC)and complications or comorbidities(CC)in surgical cases at a specialized oncology hospital under the background of the China healthcare security diagnosis related groups(CHS-DRG)payment system,and to quantify the impact of these errors on DRG relative weight and healthcare insurance payment performance,thereby providing a basis for improving the quality of medi-cal record data.Methods A total of 1 023 discharged medical records(including surgical records of lung malignant tumors,colon malignant tumors and rectal malignant tumors)from Affiliated Cancer Hospital and Institute of Guangzhou Medical University from January to December 2024 were retrospectively selected.An expert panel was established to perform a specialized review and simulated re-coding of MCC/CC based on International Statistical Classification of Diseases and Related Health Problems,10th Revision(ICD-10)coding rules and medical documentation(including progress notes,labo-ratory results,and medical orders).The DRG grouping re-sults and case mix index(CMI)values before and after the coding revision were compared,and the economic gains and losses were simulated.Subgroup analysis was used to analyze the differences in under-coding characteristics between the lung malignant tumor group and the colorectal malignant tumor group.Results Among the 1 023 sampled cases,under-coding of MCC/CC was identified in 122 cases,representing an un-der-coding rate of 11.9％.The top three diagnoses with the highest incidence of under-coding were hypoproteinemia(E88.0),tumor-related anemia(D63.0*),and pulmonary infection(J98.4).Following the correction of codes,the DRG grouping changed for 102 cases,resulting in a variation rate of 10％.The total relative weight increased by 48.6,and the case mix index(CMI)rose from 1.186 to 1.233.The simulation indicated a recovery of approximately 729 000 yuan in healthcare insurance fund losses.Subgroup analysis showed that the under-coding rate in the colorectal malignant tumor group(14.6％)was higher than that in the lung malignant tumor group(9.7％),with statistically significant difference(P<0.05),and the ef-fect size analysis suggested a weak correlation(Cramer's V=0.075).Conclusion Patients undergoing tumor surgery often present with complex metabolic and consumptive disorders.However,clinicians frequently demonstrate insufficient attention to non-surgical comorbidities,leading to severe under-coding of"occult"MCC/CC.Establishing an intelligent"laboratory-coding"verification mechanism and implementing a coder clinical rotation system can significantly improve the accuracy of DRG grouping and the operational efficiency of the hospital.