研究目的:評估ICD-10-CM/PCS導入對TW-DRGs健保支付費用之影響。有鑑於這兩種編碼系統架構差異相當大，總代碼數增加約8倍之多，ICD-9-CM疾病代碼有16%、處置有90%無法一對一轉換，可能會對以疾病代碼為基本分類架構的TW-DRGs造成影響。
方法:以2014年1月至6月中部某醫學中心，全民健康保險國際疾病分類第十版編碼實作獎勵方案申報資料共35,239件住院案件，依據申報之ICD-9-CM及ICD-10-CM/PCS代碼，分別以ICD-9及ICD-10兩種TW-DRGs版本進行編派，扣除DRG空白值者與非DRG案件，研究對象共27,517件，分析比較相同案件兩種版本TW-DRGs編派不一致率及總權重差異率，評估版本轉換後對TW-DRGs編派及健保給付所造成之影響。
結果:ICD-10-CM/PCS版與ICD-9-CM版TW-DRGs不一致率高達28.27%，顯示2種版本DRG編派結果有明顯差異。總權重下降-0.23%，且ICD-10版本醫療費用變異係數>50%比率較ICD-9版本明顯增加，健保住院給付費用會下降，影響甚鉅。
Objective:
Since January 1, 2016, the health care reporting code in Taiwan has been fully converted from ICD-9-CM(2001) to ICD-10-CM/PCS(2014). Total coding numbers of ICD-10-CM/PCS is about 8 times to ICD-9-CM coding numbers. The system structure between these two coding system is very different. It may also causes TW-DRGs changes. To estimate the impact on aggregate payments based on the TW-DRGs assigned using ICD-9-CM coded data with the ICD-9-CM version of the TW-DRGs are compared to ICD-10-CM/PCS coded date with the ICD-10-CM/PCS version of the TW-DRGs is very important.
Methods:
This paper uses the coding data since 2015 January to June. Payment based on the TW-DRGs assigned using ICD-9-CM coded data with the ICD-9-CM version of the TW-DRGs are compared to payment based on the TW-DRGs assigned using ICD-10-CM/PCS coded data with the ICD-10-CM/PCS version of the TW-DRGs. Use relative weight to estimate the payment between ICD-9-CM and ICD-10-CM/PCS TW-DRGs version. This paper will use total aggregate relative weight in each MDC(Major Diagnostic Categories) group, to compare between these two TW-DRGs, and use the Coefficient of Variance in each TW-DRGs medical cost, to identify ICD-10-CM/PCS version TW-DRGs should recheck its rules or not.
Result:
7,778(28.27%) cases had changed in ICD-10-CM/PCS TW-DRGs assignment. Total relative weight decrease 76.67, 44.90% shifted to higher-weight TW-DRGs, 55.10% shifted to lower-weight TW-DRGs. Aggregate weight change was -0.23%.
Conclusion:
The results of this study show that aggregate payments will decrease on ICD-10-CM/PCS TW-DRGs, and suggest to revise ICD-10-CM/PCS TW-DRGs rules, not just mapping from ICD-9 version. Hospitals need to take serious on this, and prepare on this change as early as they can.
