Download Penentuan Diagnoses Pulang

SESE 12a
PENENTUAN
DIAGNOSES PULANG
(WHO)
Disusun oleh
dr. Mayang Anggraini Naga
(Revisi 2015)
1
DESKRIPSI
• Untuk mencegah kerugian akibat tertahannya
atau keterlambatannya penyelesaian kode
diagnosis(es) pulang pasien sebagai penentu
besaran biaya tagihan rawat asuhan medis dan
pelayanan rumah sakit
Pengkode harus bekerja
secara
presisi, akurat dan tepat.
2
KOMPETENSI
-
Mampu mengerti
Arti diagnosis(-es) dalam penentuan
biaya rawat.
Cara memilih diagnosis final pasien
Cara penyelesaian kode diagosis(-es)
Cara mencegah kerugian yang bisa terjadi
akibat penentuan diagnosis pulang yang
salah
3
WHO
Problem pada Saat Menentukan
Discharge Diagnose
Kesulitan sering timbul:
(1)Pada saat membedakan antara:
“Principal diagnose(is)” dari
Most Significant Diagnose”
yang terkadang bisa sama.
(2)Apabila istilah
“Primary” dan “Secondary Diagnose” digunakan
bersama dan tidak jelas perbedaannya dengan
“Principal dan Most Significant atau Additional
Diagnoses”
4
Adakalanya:
Diagnosis Pokok (Principal)
bukan Primary Diagnose (utama)
Mengapa?
Diagnosis pokok menjadi alasan kuat untuk
pasien admisi masuk rawat
namun:
Bisa juga bahwa akhir rawat ternyata
memang diagnosis pokok ini adalah
=
“Primary Diagnose”
5
Panduan Penentu Diagnosis Pokok
• Telaah seluruh RM/HR  cari diagnosis pokok
• Diagnosis pokok bisa cocok dengan admitting
diagnosis (diagnosis masuk) atau problem
• Mungkin saja komplikasi yang sudah ada waktu
admisi adalah diagnosis pokok
• Diagnosis yang ditulis di urutan teratas oleh
dokter belum tentu diagnosis pokok.
6
Diagnoses Lain-Lain
PRINCIPAL DIAGNOSIS
The Diagnosis of the Condition
Established after Study to be
the Chiefly responsible for the Occasioning
the Admission of the Patient
to the Hospital for Care
7
PRIMARY DIAGNOSIS
Tradisional digunakan pada
DATA VITAL STATISTIC RECORDS
Mengacu ke Underlying Condition
atau
CAUSE of DEATH atau
MORBIDITY
“Primary” sering dicampuradukkan dengan
“Most Significant”  dan belum ada definisi
universal yang memberi batasan pengertian
kedua istilah ini!
8
“PRINCIPAL” and “Other” Diagnosis
M.B.D.S lebih condong menggunakan:
“Principal” dan “Other”
dengan tujuan utama: untuk menjelaskan
EPISODE PERAWATAN RUMAH SAKIT
juga
“Additional” lebih disukai daripada “Secondary”
 ini tidak memberi kesan seolah ada
diagnoses yang kurang penting secara klinis.
9
DISCHARGE DIAGNOSIS
• (Diagnose pulang/selesai satu episode rawat)
SATU dari DIAGNOSES yang TEREKAM
yang dipilih setelah AKUMULASI DATA
Selama
EPISODE PASIEN DIRAWAT/MEMPEROLEH
ASUHAN MEDIS  DIKAJI
Disebut: “FINAL DIAGNOSIS”
LIST OF DISCHARGE DIAGNOSES
= seperangkat
DAFTAR DISCHARGE DIAGNOSES
Seorang PASIEN RAWAT INAP
10
OTHER DIAGNOSIS
A DIAGNOSIS,
other than Principal Diagnosis
that describes a condition for which
a patient receives treatment or which
the physician considers of sufficiencies
to warrant inclusion for investigative
medical studies
11
COMPLICATION
An Additional Diagnosis that
Describes a Condition
arising after the beginning of
hospital observation and treatment
and modifying the course of
the patient illness
or
the medical care required
12
Komplikasi memiliki art sempit:
• Apabila: It describes an Undesired Result
or Misadventure in medical care of
hospital patient.
such as:
decubitus ulcer
post-op hemorrhage
adverse effect of medicinal agent
hospital aquired infection
(nosocomial-infection)
surgical emphysema, etc.
13
Komplikasi memiliki arti luas:
• Apabila:
It denotes any condition concurrent
with the condition described in the
Principal Diagnosis
regardless of the time of it’s onset.
14
Most Significant Diagnosis
The one diagnosis,
often but not necessarily
the Principal Diagnosis that describes the
most important or significant condition of
a patient in term of its implications for
his/hers health,
his/hers medical care,
his/hers use of the hospital
15
Asuransi Kesehatan membedakan secara
tegas antara:
• COMPLICATION:
Complication is a condition that arises during the
hospital stay that prolongs the patient’s LOS by
at least ONE day in 75% of the cases
• COMORBIDITY
Comorbidity is a pre-existing condition that will,
because or it’s present with a specific principal
diagnosis cause  an increase in the patient’s
LOS by at least ONE day in 75% of the cases.
16
CONTOH:
Pasien A:
1. Appendicitis acuta  rawat untuk pembedahan  terlaksana
2. D. Mellitus  co-morbiditas
3. Emphysema pulmonum  gangguan kronik
4. Luka operasi  tidak menyembuh sempurna
 memperpanjang LOS pasien
1 = P = Most sig. diag.
2 dan 3 = Additional diag.
4 = complication
17
CONTOH:
Pasien B:
1. Fracture femoris dextra
2. MCI acute, anterior wall  timbul saat dirawat
 LOS >> dan menjadi alasan terapi
selanjutnya
1.
= P diag.
2.
= Most. Sig. diag. (walau sebagai
additional diag. terhadap keadaan
pada 1)
18
CASEMIX-ADJUSTED
=
Statistics where the effects
of variations in case-mix have
been taken into account.
19
CASEMIX-ADJUSTED COST
PER INPATIENT
= The total cost of provision of inpatient
care, divided by total inpatients treated;
and adjusted to take account of the
actual mix of patients treated and
differences in the mean costs of
casemix classes
20
CASEMIX-BASED FUNDING
= A method of funding similar
(and in some circumstances identical)
to output-based funding.
Involves funding of the health care
products of health care delivery units,
where the products are categorized
using CASEMIX CLASSIFICATION.
21
TASK WHERE PATIENT CLASSIFCATION CAN HELP
• Deciding whether re-admission rates are abnormally
high
• Deciding whether too many or too few pathology
tests are being ordered
• Finding and fixing problems of poor outcome for
rehabilitation patients
• Designing benefits structures in private insurance
• Deciding how resources should be allocated
between public hospitals
• Allocating funds between hospital departments
• Planning bed and staff numbers for new hospital
• Investigating whether the nurse staffing mix needs
to be changed.
22
USES OF PATIENT CLASSIFICATION
• Patient classifications are useful because they
help us to find differences in:
outcome,
quality, or
cost of care.
• By understanding the differences, health care
professional find opportunities to make health care
more effective.
• Casemix seeks to improve classification of patients
care episodes and put them to better use.
23
3 (three) FEATURES OF CASEMIX
(1) Clinical meaning (patients in the same class
should have clinical similarities)
The episodes in a class should involve
similar kinds of;
presenting problems,
treatment methods and
outcomes.
It is not sufficient merely to ensure that each class
contains episodes which are similar in cost.
Casemix is designed to ensure every class
makes sense to clinicians.
24
CLASS
A class defined as “patients who were in
hospital for over 20 days” might contain
episodes which are similar in terms of
resource used, but it has little clinical
meaning, because there are many different
reasons for long stays (major trauma,
need for rehabilitation, social problems
which delay discharge)
25
FEATURES OF CASEMIX (CONT.-1)
Resource use homogeneity (patients in
the same class should cost roughly the
same treat).
Classes is designed in such a way that
episodes which required similar levels of
resource are assigned to the same
class.
(Is defining classes by surgical and medical
is better than forming them by age?)
26
FEATURES OF CASEMIX (CONT.-2)
In the real world, many more patient care episodes
and many more attributes,
(such as diagnoses, functional abilities, and type of
admission) must be considered.
 apply statistical methods to find and evaluate all the
options
 Finding rules which define the classes in such a
way that episodes in the same class are similar in
terms of resource use.
27
FEATURES OF CASEMIX (Cont.-3)
(3) The right number of classes (neither too few or too
many) (optimal numbers of classes)
It is difficult to know how many classes of patient care
episodes there should be.
Too many classes will have too few observations to
allow conclusions to be drawn.
Then it would be impossible to know whether a
hospital is really different, or whether analyses are
merely showing the kind of variability which is normal
in small samples.
28
FEATURES OF CASEMIX (Cont.-4)
On the other hand there should not be too few classes.
If large numbers of dissimilar cases are placed in
the same class, real differences between doctors,
nurses, hospitals and so on will be concealed and
clinical meaning will be lost.
 A compromise is needed.
 A statistical methode is needed.
29
CONTOH: pemanfaatan Case-Mix
Minnesota Case Mix (Facility Manual for Case Mix
Classification) March 21, 2003
• Case Mix”
is a means of classifying care that is based on the
intensity of care and services provided to the
resident)
(adalah cara pengklasifikasian asuhan berbasis
intensitas asuhan dan tipe pelayanan yang
diselenggarakan bagi pasiennya)
(Minnesota memiliki 34 klasifikasi case-mix berserta
besaran tarip pembayarannya, penalty dan
kegagalannya).
30
CONTOH: Minnesota ….
• Undang-undang negara bagian (USA) mengatur
bahwa semua fasilitas perawatan menagih pasien
yang bayar sendiri dan pasien asuransi (Medicaid)
berdasarkan tarif pelayanan yang sama berbasis
klasifiaksi case-mix-nya.
• Artinya:menggunakan “equalization” rate dan
mengharuskan semua pasien dalam fasilitas
perawatan ditagih dengan tarif yang sama bagi
asuhan dan pelayanan yang sama.
31
CASEMIX - DRGs
The size of database depends on the
number of patients care episodes
which are to be analyzed using the
classification.
32
CASEMIX - DRGs (Lanjutan-1)
The extended use: a classification with
few classes might be ideal for some
strategic management purposes,
but
less so for a private hospital
which is dependent for its financial
survival on very precise description
of it casemix.
33
CASEMIX - DRGs (Lanjutan-2)
• Many assumed there is only one casemix
classification.
DRGs is the most used casemix classification
in the last decade  the use of DRGs for
resource allocation deserves special attention.
 trend is towards a wider range of uses
of many more casemix classifications
34
A MORE PRECISE STATEMENT ABOUT
CASEMIX
• CASEMIX IS part of a science approach to
producing good information about health
care
• IT FOCUSES ON building useful classifications
of patients care episodes
AND making good use of patient care
classifications to manage health care.
35
A MORE PRECISE STATEMENT ABOUT CASEMIX (Lanjutan)
Casemix has to be complicated if it is to
help resolve real problems.
There would be little sense in simplifying
casemix ideas and tools so much that
they would no longer be relevant to the
real world.
Their complexity merely reflects the nature
of health care, and if used properly they
make the world less, not more, confusing.
36
Requirements for Case-mix System
(1)
Accurate diagnosis
Primary Diagnosis
* Principle Diagnosis
- Main Reasons for admission
- used to assign MDC
Secondary Diagnosis
* Complication
* Co-morbidities
37
Requirements for Case-mix System
(2)
• Costing Data
*
Charges
*
Step-down costing
*
Case-Mix costing
*
Acivity based costing
- for selected conditions
38
Requirements for Case-mix System
(3)
• Classification System
*
Disease Classification
- ICD-10
*
Procedures Classificaion
- Surgical procedures
- Non-surgical procedures
39
Requirements for Case-mix System
(4)
• Health Management Information System
- Properly established: hardware & software
- Trained manpower: trained coders
- Proper record keeping
- Budgets to maintain HMIS
40
Requirements for Case-mix System
(5)
• Support from Hospital Management
- Quality Assurance Programme
Medical Audit
Hospital Benchmarking
- Use Case-Mix System
Appropriate feed-back to Clinicians
Negotiates funding with potential
funders.
41
DRGs (Diagnosis-Related Groups)
Ini adalah klasifikasi pasien rawat.
DRGs are designed to catagorise
acute inpatient episodes, but
CASEMIX classifications have
been developed for other kinds of
episodes:
outpatients,
nursing home care.
42
DRG (Lanjutan-1)
(1) The first step involves looking at the principle
diagnosis
= the diagnosis or condition established
after study to be chiefly responsible for
the patient’s admission to hospital.
(2) The significant procedure performed and
check the kind of procedure.
43
DRG (Lanjutan-2)
(3) Taking account on the patient’s age
(children or old)
(4) COMPLICATIONS or COMORBIDITIES
(5) Types of discharge.
44
AN- Casemix Dictionary
• The Australian Casemix Dictionary
(Department of Human Services and Health):
Diagnoses clusters:
A classification system developed
in the early 1970s. Which only made
use of diagnoses.
(AVGs = Ambulatory Visit Groups)
45
AHIMA & AN-DRG
Diagnosis chiefly responsible for services
provided (out patient) =
The diagnosis, condition, problem, or reason
for encounter/visit that is chiefly responsible
for the services provided.
If a definitive diagnosis has not been established
at the end of the visit/encounter, the condition s
hould be recorded to the highest documented
level of specificity (such as symptoms, signs,
abnormal test results, or other reason for visit).
46
AHIMA & AN-DRG (Lanjutan)
•
•
•
•
•
•
The main variables which influence AN-DRG
assigment include:
Principal diagnosis (ICD-CM code)
Procedure codes (ICD-CM code)
Secondary diagnoses (ICD-CM code)
Age and gender
Birth weight (neonatus only)
Dischage status
47
AN-DRG
1.
PDX is used to assign the episode of care to one of
23 Major Diagnostic Categories (MDCs) MDCs
correspond generally to the main organ systems of the
body.
The following specific variables are exceptions:
- Age less than 29 days
- Principal diagnosis which is a specific neonatal
disorders
- Principal or secondary diagnosis of HIV
- Liver transplant
- Bone marrow transplant
- Principal diagnosis of multiple trauma
- Tracheostomy procedure.
48
AN – DRGs (Lanjutan-1)
2. Medical or surgical partition according to
whether a significant operating room (OR)
procedure has been performed. It is to be
noted that not all procedures are considered
significant OR procedures.
3. Sub grouping based on the precise surgical
procedure performed or, for medical patients,
the precise condition designated as the
principal diagnosis.
49
AN – DRGs (Lanjutan-2)
4. Final assignment to a DRG is usually made
by age or the existence of a complicating
diagnosis and/or comorbidity (CC)*
•
A substantial complication or comorbidity (CC)
is defined as a condition that because of its
presence with a specific principal diagnosis,
would cause an increased in the length of stay
by at least one day.
50
PRINCIPAL DIAGNOSIS
The diagnosis or condition established
after study to be chiefly responsible for
occasioning the patient’s admission to
hospital.
(AN-standard definition. One of the two most
important variables used to define AN-DRG
classes)
51
SECONDARY DIAGNOSES
Any condition additional to the principal
diagnosis which affects patient care by
requiring clinical evaluation, therapeutic
treatment, diagnostic procedures, extended
LOS, or increased nursing care or
monitoring. Includes complications and
comorbidities.
52
PRINCIPAL PROCEDURE
The procedure performed for definitive
treatment rather than for diagnostic or
exploratory purposes.
In the context of assignment to an AN-DRG
class, selection of one procedures as principal
is not necessary.
PROCEDURE
A therapeutic intervention.
Procedures are coded using ICD-9-CM.
One of the two most important variables
used to define DRG classes.
53
PROCEDURE HIERARCHIES
•
List of procedures in order of their relative costliness.
Assignment to an AN-DRG is on the basis of the
highest ranking procedure only, where two or more
were undertaken. Ranking is determined by the
computer software (the Grouper).
PROCEDURE REVIEW
A type of utilization review which involves assessing
the patient’s need for diagnostic and therapeutic
procedures.
54
PROSPECTIVE PAYMENT SYSTEM PPS
A type of output-based funding formula, whereby
health care providers (usually hospitals) receive
predetermined payments for each episode of care
defined by casemix classes. (Usually DRGs)
The term was first used for US Medicare’s DRG-based
payment system for hospitals.
PATIENT CLASSIFICATION SYSTEM
• (Private Hospital) A simple casemix classification
for inpatient episodes which is used to bill for all
services excepting critical care and operating
rooms.
55
SELAMAT MEMBACA
Semoga dapat
Membantu untuk lebih memahami
kegunaan
Sistem Pelayanan Asuransi Kesehatan,
satu program pelayanan,
yang sedang digalakkan
Kementerian Kesehatan
56