Zeitaufwand für Diagnosekodierung - am Beispiel der "Ambulanten Kodierrichtlinie"

Diagnoses Codes are an important base for the cash flow of German health care/insurances (morbidity-risk structural compensation – Morbi-RSA). In the light of the well-known timely and personal burden in health care, diagnoses codes are interesting, too. Actually there is no scientific information available, neither on the question, how much time coding takes, nor on coding procedures and its financial consequences in Germany. Focus so far has been set only on the validity of coding, regarding medical aspects. In the „practica“-survey (practica is a German family practitioner’s postgraduate training event) in 2010 it was no wonder, that two thirds of the 150 participants would welcome an easier coding-system with ICPC-2 surface and direct mapping to ICD-10 2011, German modification. This was in times of the projected implementation of the Ambulant Coding Guideline (AKR), which was suspected to lead to an increasing of the burden of bureaucracy for practicing physicians. The time for coding and its strategies was first acquired in the HEISA-trial, via self-reporting. Then it was measured quantitatively and in regard of its financial consequences in the Ms.-Boyd-trial, by coding 9 diseases of a typical multi-morbid Patient. Coding is doctor’s work. In HEISA-1 it was considered a reasonable base for documenting the indication for medication, allergies, results of illnesses, and for documenting therapy. 60% managed coding in less than a minute, whereas it was 85% in the „practica“-survey. In HEISA-2 only 35% could do so, when having AKR-standards activated. 50% had severe problems while implementing AKR and expected higher costs for computers and personnel. Consulting Physicians did not seem to see this that critical, reasonably because of the lower amount of diseases to be coded. In the Ms.-Boyd-trial coding should be performed by three means: as usual, according to AKR and by using the CodA-list (a mapping of ICPC-2 classification to ICD). Coding according to AKR took more than a double of the time compared to the other methods. The correctness of codes didn’t differ, contrary to financial consequences: having coded correctly, 831 euros per month would have been paid to the patient’s health insurance via Morbi-RSA. Only the AKR-method could reach this goal approximately on an average, while the results of up-coding where seen clearly. This makes the appropriateness of the ICD not only as fundament to the Morbi-RSA doubtful, but also when the doctor’s fee is calculated on his patients’ morbidity. This is stressed by the fact, that wrong-coding could cause a financial harm of around 6.000 euros to the patients insurance a year, considering only this one patient. The main argument against coding by the AKR-method is the amount of time needed for it, especially considering the demographic development in general and the decreasing numbers of doctors in Germany. After the publication of the „practica“-survey, a petition against AKR to the German parliament and intensive discussions in- and outside German doctor’s self-administration, coding according to AKR was not implemented, but a simpler, though less compulsory GP’s subset of the ICD-10. Since better coding of diseases is still reasonable in the German Morbi-RSA-System and is also implemented in some conducts of patients’ care, then especially considering the costs and the effectiveness of coding and generally the bureaucracy in the doctor’s office is more relevant than ever. If Germany’s need for Morbi-RSA faints, e.g. when there was only one health insurance, a high-value classification system for diseases like ICPC-2, accompanied by a translation to ICD like CodA could easier be implemented.