A method and system for analyzing drg group enrollment failures

Abstract

The application provides a DRG grouping failure analysis method and system, which comprises the following steps: obtaining first diagnoses included in each MDC and first diagnosis codes included in each ADRG; grouping the first diagnoses to obtain a first diagnosis table; grouping the first diagnosis codes to obtain a first diagnosis code table; simultaneously obtaining non-groupable diagnoses in the MDC and the ADRG; matching the non-groupable diagnoses with the groups in the first diagnosis table and the first diagnosis code table respectively according to individual characteristic values, and if the matching is successful, storing the non-groupable diagnoses in the corresponding groups; if the matching fails, analyzing the causes; and screening replaceable groups of the non-groupable diagnosis codes from the first diagnosis table and the first diagnosis code table. Based on the method, the application further provides a DRG grouping failure analysis system. Through the analysis of the non-groupable patients, the application informs the doctors of the causes of the non-groupable patients and gives the doctors suggestions for relevant adjustment.

Description

Technical Field

[0001] This invention belongs to the field of medical reimbursement technology, and specifically relates to an analysis method and system for DRG enrollment failure. Background Technology

[0002] DRG (Diagnosis Related Groups) is an important tool for measuring the quality and efficiency of healthcare services and for medical insurance reimbursement. Essentially, DRG is a case-group classification scheme that categorizes patients into several diagnostic groups based on factors such as age, disease diagnosis, comorbidities, complications, treatment methods, disease severity, outcome, and resource consumption. DRG payment is a crucial means to achieve a win-win situation for healthcare providers, insurance companies, and patients, and to promote the transformation of the service model through hierarchical medical care. It involves payment based on diagnosis-related groups, meaning that related diseases are grouped together and paid for as a package, rather than being paid for item by item. The DRG grouping process is as follows: cases are assigned to the Major Diagnostic Category (MDC), then to the Adjacent Diagnosis Related Group (ADRG) within the MDC, and finally to the corresponding DRG group, generating a corresponding DRG code. Currently, DRG is one of the mainstream methods for medical insurance reimbursement, and it has been implemented in over a hundred cities. The current DRG medical insurance reimbursement process is: patient grouping, weight calculation, and reimbursement. Therefore, whether patient medical record data / settlement list data can be included in the reimbursement process directly affects the reimbursement situation.

[0003] The DRG (Diagnosis Related Groups) medical insurance payment reform has only recently been implemented, and most physicians are unfamiliar with it. Therefore, when filling out medical record front pages / settlement lists, they lack the concept of DRG enrollment and cannot consciously make adjustments, resulting in many patients being unable to enroll. Furthermore, in the current grouping system, if a patient is not enrolled, the system can only notify the physician that the patient cannot be enrolled. It does not provide information on the reasons for the patient's non-enrollment or how to adjust the system to enable enrollment. This leaves physicians unable to understand the reasons for non-enrollment and unable to make any necessary changes. Summary of the Invention

[0004] To address the aforementioned technical issues, this invention proposes an analysis method and system for DRG enrollment failures. It compiles a data dictionary that easily leads to non-enrollment, and through the analysis of non-enrolled patients, informs physicians of the reasons for the non-enrollment and provides physicians with relevant adjustment suggestions.

[0005] To achieve the above objectives, the present invention adopts the following technical solution:

[0006] An analytical method for DRG enrollment failure includes the following steps:

[0007] Obtain the first diagnosis included in each MDC and the first diagnosis code included in each ADRG; group the first diagnoses according to a first preset standard to obtain a first diagnosis table; and group the first diagnosis codes according to a second preset standard to obtain a first diagnosis code table;

[0008] Obtain the ineligible diagnoses from each MDC and the ineligible diagnosis codes from each ADRG;

[0009] Based on the individual characteristic values, the diagnoses that cannot be included in the group are matched with the groups in the first diagnostic table and the first diagnostic coding table. If the match is successful, the diagnoses are stored in the corresponding group; if the match fails, the reasons for the failure are analyzed; and alternative groups for the diagnoses that cannot be included in the group are selected from the first diagnostic table and the first diagnostic coding table.

[0010] Furthermore, the first preset criterion is whether the influence of individual patient characteristics needs to be considered; the first diagnostic table includes data affected by individual patient characteristics and data not affected by individual patient characteristics.

[0011] Furthermore, the second preset standard is the treatment method; the first diagnostic coding table includes the included surgical procedures and the included diagnostic procedures.

[0012] Furthermore, the ineligible diagnosis in the MDC refers to data in the MDC where individual characteristic values ​​were missing or incorrectly filled in.

[0013] Furthermore, the ineligible diagnostic codes are diagnostic codes that exist in the MDC but not in the ADRG and diagnostic codes that exist in the ADRG but not in the MDC.

[0014] Furthermore, the process of matching diagnoses that cannot be included in the group with the groups in the first diagnostic table and the first diagnostic coding table based on individual characteristic value data, and storing the diagnoses in the corresponding group if a match is successful; and analyzing the reasons for failure if a match fails, includes:

[0015] Determine whether a corresponding individual feature value exists in the first diagnostic table and the first diagnostic coding table; if it exists in either the first diagnostic table or the first diagnostic coding table, store it in the corresponding group; if it does not exist in either table, the matching fails, and the reason for the failure is analyzed.

[0016] Furthermore, the method also includes storing the unacceptable grouping diagnosis that failed to match into a preset pending group under MDC or a preset pending group under ADRG.

[0017] Furthermore, the process of filtering out alternative groupings of ineligible diagnostic codes from the first diagnostic table and the first diagnostic code table includes:

[0018] Filter out diagnostic codes that exist in the MDC but not in the ADRG from the existing ADRG;

[0019] Filter out diagnostic codes from the existing MDC that exist in ADRG but not in MDC.

[0020] The present invention also proposes an analysis system for DRG enrollment failure, comprising: a first acquisition module, a second acquisition module, and an analysis module;

[0021] The first acquisition module is used to acquire the first diagnosis included in each MDC and the first diagnosis code included in each ADRG; group the first diagnoses according to a first preset standard to obtain a first diagnosis table; and group the first diagnosis codes according to a second preset standard to obtain a first diagnosis code table;

[0022] The second acquisition module is used to acquire the ineligible diagnoses in each MDC and the ineligible diagnosis codes in each ADRG;

[0023] The analysis module is used to match the diagnoses that cannot be included with the groupings in the first diagnosis table and the first diagnosis code table based on the data of individual characteristic values. If the match is successful, it is stored in the corresponding group; if the match fails, the reason for the failure is analyzed; and alternative groups for diagnoses that cannot be included are selected from the first diagnosis table and the first diagnosis code table.

[0024] Furthermore, the process executed by the analysis module includes:

[0025] Determine whether a corresponding individual feature value exists in the first diagnostic table and the first diagnostic coding table; if it exists in either the first diagnostic table or the first diagnostic coding table, store it in the corresponding group; if it does not exist in either table, the matching fails, and the reason for the failure is analyzed; and filter out diagnostic codes that exist in the MDC but not in the ADRG from the existing ADRG; filter out diagnostic codes that exist in the ADRG but not in the MDC from the existing MDC.

[0026] The effects described in the invention are merely those of the embodiments, and not all the effects of the invention. One of the above technical solutions has the following advantages or beneficial effects:

[0027] This invention proposes a method and system for analyzing DRG enrollment failures. The method includes: obtaining the first diagnosis included in each MDC and the first diagnostic code included in each ADRG; grouping the first diagnoses according to a first preset standard to obtain a first diagnostic table; and grouping the first diagnostic codes according to a second preset standard to obtain a first diagnostic code table; obtaining ineligible diagnoses in each MDC and ineligible diagnostic codes in each ADRG; matching the ineligible diagnoses with the groups in the first diagnostic table and the first diagnostic code table based on individual characteristic values; if a match is successful, storing the diagnoses in the corresponding group; if a match fails, analyzing the reasons for the failure; and selecting alternative groups for the ineligible diagnostic codes from the first diagnostic table and the first diagnostic code table. Based on this method for analyzing DRG enrollment failures, this invention also proposes a system for analyzing DRG enrollment failures. This invention analyzes the grouping scheme and enrollment logic to compile a data dictionary that easily leads to non-enrollment. Through analysis of non-enrolled patients, it informs physicians of the reasons for non-enrollment and provides physicians with relevant adjustment suggestions. Attached Figure Description

[0028] Figure 1 This is a flowchart of an analysis method for DRG enrollment failure according to Embodiment 1 of the present invention;

[0029] Figure 2 This is a schematic diagram of MDC and ADRG grouping in Embodiment 1 of the present invention;

[0030] Figure 3 This is the process for handling enrollment failure in Embodiment 1 of the present invention;

[0031] Figure 4 This is a schematic diagram of an analysis system for DRG enrollment failure according to Embodiment 2 of the present invention. Detailed Implementation

[0032] To clearly illustrate the technical features of this solution, the invention will be described in detail below through specific embodiments and in conjunction with the accompanying drawings. The following disclosure provides many different embodiments or examples for implementing different structures of the invention. To simplify the disclosure of the invention, components and arrangements of specific examples are described below. Furthermore, reference numerals and / or letters may be repeated in different examples. This repetition is for simplification and clarity and does not in itself indicate a relationship between the various embodiments and / or arrangements discussed. It should be noted that the components illustrated in the drawings are not necessarily drawn to scale. Descriptions of well-known components, processing techniques, and processes are omitted in this invention to avoid unnecessarily limiting the invention.

[0033] Example 1

[0034] This invention proposes an analysis method for DRG enrollment failure, aiming to solve the technical problem of DRG enrollment failure in existing technologies. For example... Figure 1 This is a flowchart of an analysis method for DRG enrollment failure according to Embodiment 1 of the present invention;

[0035] In step S100, the first diagnosis included in each MDC and the first diagnosis code included in each ADRG are obtained; the first diagnoses are grouped according to a first preset standard to obtain a first diagnosis table; and the first diagnosis codes are grouped according to a second preset standard to obtain a first diagnosis code table.

[0036] MDC (Major Diagnostic Category) refers to the major diagnostic category.

[0037] ADRG (Adjacent Diagnosis Related Group) is a core disease diagnosis-related group.

[0038] like Figure 2 This is a schematic diagram of MDC and ADRG grouping in Embodiment 1 of the present invention;

[0039] The main diagnoses included in each MDC and the main diagnostic codes included in each ADRG are compiled.

[0040] The first presupposition criterion is whether the influence of individual patient characteristics needs to be considered; the first diagnostic table includes data affected by individual patient characteristics and data not affected by individual patient characteristics. Therefore, this application divides MDC into two categories based on whether individual patient characteristics are required for inclusion in the data: those affected by individual patient characteristics and those not affected by individual patient characteristics.

[0041] The second presupposed standard is the treatment method; the first diagnostic coding table includes the included surgical procedures and the included diagnostic procedures. Therefore, this application divides ADRG into four categories according to the enrollment type: "includes the following major surgical procedures... and...", "requires inclusion of the following major diagnoses... and also includes the following major surgical procedures...", "includes the following major surgical procedures", and "includes the following major diagnostic codes".

[0042] In step S200, the ineligible diagnoses in each MDC and the ineligible diagnoses codes in each ADRG are obtained;

[0043] Based on the grouping logic of the national DRG technical specifications and big data statistics, the following situations were identified as unsuitable for inclusion in the group: omission or incorrect filling of patient individual characteristics, some diagnoses existing in the MDC but not in the ADRG, and some diagnoses existing in the ADRG but not in the MDC.

[0044] In step S300, based on the individual characteristic value data, the diagnoses that cannot be included in the group are matched with the groups in the first diagnostic table and the first diagnostic code table respectively. If the match is successful, the diagnoses are stored in the corresponding group; if the match fails, the reason for the failure is analyzed; and alternative groups for the diagnoses that cannot be included in the group are selected from the first diagnostic table and the first diagnostic code table.

[0045] Determine whether a corresponding individual feature value exists in the first diagnostic table and the first diagnostic coding table; if it exists in either the first diagnostic table or the first diagnostic coding table, store it in the corresponding group; if it does not exist in either table, the matching fails, and the reason for the failure is analyzed.

[0046] The method also includes storing the diagnosis of unmatched non-grouping in a preset pending group under MDC or a preset pending group under ADRG.

[0047] The process of selecting alternative groupings for ineligible diagnostic codes from the first diagnostic table and the first diagnostic coding table includes:

[0048] Filter out diagnostic codes that exist in the MDC but not in the ADRG from the existing ADRG;

[0049] Filter out diagnostic codes from the existing MDC that exist in ADRG but not in MDC.

[0050] Embodiment 1 of this invention proposes an analysis method for DRG enrollment failure. By analyzing the grouping scheme and enrollment logic, a data dictionary that is prone to causing non-enrollment is compiled. Through the analysis of patients who are not enrolled, the method informs the physician of the reasons for the non-enrollment and provides the physician with relevant adjustment suggestions.

[0051] Example 2

[0052] Based on the analysis method for DRG enrollment failure proposed in Embodiment 1 of the present invention, Embodiment 2 of the present invention also proposes an analysis system for DRG enrollment failure, which includes: a first acquisition module, a second acquisition module and an analysis module.

[0053] The first acquisition module is used to acquire the first diagnosis included in each MDC and the first diagnosis code included in each ADRG; group the first diagnoses according to a first preset standard to obtain a first diagnosis table; and group the first diagnosis codes according to a second preset standard to obtain a first diagnosis code table;

[0054] The second acquisition module is used to acquire the ineligible diagnoses in each MDC and the ineligible diagnosis codes in each ADRG.

[0055] The analysis module is used to match the diagnoses that cannot be included with the groupings in the first diagnosis table and the first diagnosis code table based on the data of individual characteristic values. If the match is successful, it is stored in the corresponding group; if the match fails, the reason for the failure is analyzed; and alternative groups for diagnoses that cannot be included are selected from the first diagnosis table and the first diagnosis code table.

[0056] The analysis module execution process includes:

[0057] Determine whether a corresponding individual feature value exists in the first diagnostic table and the first diagnostic coding table; if it exists in either the first diagnostic table or the first diagnostic coding table, store it in the corresponding group; if it does not exist in either table, the matching fails, and the reason for the failure is analyzed; and filter out diagnostic codes that exist in the MDC but not in the ADRG from the existing ADRG; filter out diagnostic codes that exist in the ADRG but not in the MDC from the existing MDC.

[0058] In this application, the process performed by the first acquisition module includes: sorting out the main diagnoses contained in each MDC; sorting out the main diagnostic codes contained in each ADRG.

[0059] The first presupposition criterion is whether the influence of individual patient characteristics needs to be considered; the first diagnostic table includes data affected by individual patient characteristics and data not affected by individual patient characteristics. Therefore, this application divides MDC into two categories based on whether individual patient characteristics are required for inclusion in the data: those affected by individual patient characteristics and those not affected by individual patient characteristics.

[0060] The second presupposed standard is the treatment method; the first diagnostic coding table includes the included surgical procedures and the included diagnostic procedures. Therefore, this application divides ADRG into four categories according to the enrollment type: "includes the following major surgical procedures... and...", "requires inclusion of the following major diagnoses... and also includes the following major surgical procedures...", "includes the following major surgical procedures", and "includes the following major diagnostic codes".

[0061] In the second acquisition module: combining the grouping logic of the national technical specifications for DRG and big data statistics, the following situations were identified as unsuitable for inclusion: omission or incorrect filling of patient individual characteristics, some diagnoses existing in MDC but not in ADRG, and some diagnoses existing in ADRG but not in MDC.

[0062] Embodiment 2 of this invention proposes an analysis system for DRG enrollment failure. By analyzing the grouping scheme and enrollment logic, a data dictionary that is prone to causing non-enrollment is compiled. Through the analysis of patients who are not enrolled, the system informs the physician of the reasons for the non-enrollment and provides the physician with relevant adjustment suggestions.

[0063] For a description of the relevant parts of the DRG enrollment failure analysis system provided in this application embodiment, please refer to the detailed description of the corresponding parts in the DRG enrollment failure analysis method provided in embodiment 1 of this application, which will not be repeated here.

[0064] It should be noted that, in this document, relational terms such as "first" and "second" are used merely to distinguish one entity or operation from another, and do not necessarily require or imply any such actual relationship or order between these entities or operations. Furthermore, the terms "comprising," "including," or any other variations thereof are intended to cover non-exclusive inclusion, such that the elements inherent in a process, method, article, or apparatus that includes a list of elements are included. Without further limitations, an element defined by the phrase "comprising one..." does not exclude the presence of other identical elements in the process, method, article, or apparatus that includes said element. Additionally, portions of the technical solutions provided in the embodiments of this application that are consistent with the implementation principles of corresponding technical solutions in the prior art have not been described in detail to avoid excessive elaboration.

[0065] While specific embodiments of the present invention have been described above in conjunction with the accompanying drawings, this is not intended to limit the scope of protection of the present invention. Those skilled in the art can make other modifications or variations based on the above description. It is neither necessary nor possible to exhaustively describe all embodiments here. Various modifications or variations that can be made by those skilled in the art without creative effort based on the technical solutions of the present invention are still within the scope of protection of the present invention.

Claims

1. A method for analyzing DRG enrollment failure, characterized in that, Includes the following steps: Obtain the first diagnosis included in each MDC and the first diagnosis code included in each ADRG; group the first diagnoses according to a first preset standard to obtain a first diagnosis table; and group the first diagnosis codes according to a second preset standard to obtain a first diagnosis code table; Obtain the ineligible diagnosis from each MDC and the ineligible diagnosis code from each ADRG; the ineligible diagnosis from the MDC refers to data in the MDC where individual characteristic values ​​are missing or incorrectly filled; the ineligible diagnosis code refers to the diagnosis code that exists in the MDC but not in the ADRG and the diagnosis code that exists in the ADRG but not in the MDC. Based on the individual characteristic values, the diagnoses that cannot be included in the group are matched with the groups in the first diagnostic table and the first diagnostic coding table. If the match is successful, the diagnoses are stored in the corresponding group; if the match fails, the reasons for the failure are analyzed; and alternative groups for the diagnoses that cannot be included in the group are selected from the first diagnostic table and the first diagnostic coding table. The process of selecting alternative groupings of ineligible diagnostic codes from the first diagnostic table and the first diagnostic code table includes: selecting diagnostic codes that exist in the MDC but not in the ADRG from the existing ADRG; Filter out diagnostic codes from the existing MDC that exist in ADRG but not in MDC.

2. The method for analyzing DRG enrollment failure according to claim 1, characterized in that, The first preset standard is whether the influence of individual patient characteristics needs to be considered; the first diagnostic table includes data affected by individual patient characteristics and data not affected by individual patient characteristics.

3. The method for analyzing DRG enrollment failure according to claim 1, characterized in that, The second preset standard is the treatment method; the first diagnostic coding table includes the included surgical procedures and the included diagnostic procedures.

4. The method for analyzing DRG enrollment failure according to claim 1, characterized in that, The method involves matching the diagnoses that cannot be included in the group with the groups in the first diagnostic table and the first diagnostic coding table based on the individual characteristic values. If a match is successful, the diagnoses are stored in the corresponding group. If a match fails, the process of analyzing the reasons for the failure includes: Determine whether a corresponding individual feature value exists in the first diagnostic table and the first diagnostic coding table; if it exists in either the first diagnostic table or the first diagnostic coding table, store it in the corresponding group; if it does not exist in either table, the matching fails, and the reason for the failure is analyzed.

5. The method for analyzing DRG enrollment failure according to claim 4, characterized in that, The method further includes storing the diagnosis of unmatched non-grouping in a preset pending group under MDC or a preset pending group under ADRG.

6. A DRG enrollment failure analysis system, used to execute the DRG enrollment failure analysis method according to any one of claims 1 to 5, characterized in that, include: The module comprises a first acquisition module, a second acquisition module, and an analysis module. The first acquisition module is used to acquire the first diagnosis included in each MDC and the first diagnosis code included in each ADRG; group the first diagnoses according to a first preset standard to obtain a first diagnosis table; and group the first diagnosis codes according to a second preset standard to obtain a first diagnosis code table; The second acquisition module is used to acquire the ineligible diagnoses in each MDC and the ineligible diagnosis codes in each ADRG; The analysis module is used to match the diagnoses that cannot be included with the groupings in the first diagnosis table and the first diagnosis code table based on the data of individual characteristic values. If the match is successful, it is stored in the corresponding group; if the match fails, the reason for the failure is analyzed; and alternative groups for diagnoses that cannot be included are selected from the first diagnosis table and the first diagnosis code table.

7. The DRG enrollment failure analysis system according to claim 6, characterized in that, The process executed by the analysis module includes: Determine whether a corresponding individual feature value exists in the first diagnostic table and the first diagnostic coding table; if it exists in either the first diagnostic table or the first diagnostic coding table, store it in the corresponding group; if it does not exist in either table, the matching fails, and the reason for the failure is analyzed; and filter out diagnostic codes that exist in the MDC but not in the ADRG from the existing ADRG; filter out diagnostic codes that exist in the ADRG but not in the MDC from the existing MDC.

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