Building of an intelligent DRG grouping audit system in a hospital
10.3760/cma.j.cn111325-20240910-00788
- VernacularTitle:某三级医院DRG入组智能审核系统的建设
- Author:
Juan ZHANG
1
;
Yang PU
;
Wen LIU
;
Yingpeng WANG
;
Lianhua KONG
;
Yaxin HUANG
;
Bin WAN
;
Haixia DING
Author Information
1. 南京医科大学第一附属医院医疗保险处，南京 210029
- Publication Type:Journal Article
- Keywords:
Disease-diagnosis related groups;
Deviant behaviors;
Information system;
Intelligent audit;
Medical insurance fund
- From:
Chinese Journal of Hospital Administration
2025;41(8):614-618
- CountryChina
- Language:Chinese
-
Abstract:
Diagnosis-related groups (DRG) payment is an important component of deepening the reform of medical insurance payment methods. In June 2023, a tertiary hospital launched an intelligent DRG grouping audit system to enhance grouping accuracy. By establishing a multi departmental collaborative organizational structure, building a standardized knowledge base and a rule base covering five categories (diagnosis, fees, testing, nursing, and pathology), and integrating electronic medical records, medical orders, testing, and imaging data throughout the entire diagnosis and treatment process, the intelligent DRG grouping audit system with data collection, identification, extraction, comparison, and output modules was constructed to achieve intelligent audit. At the same time, it was formed a closed-loop management system for pre reporting quality control, in-process group entry control, and post data analysis and assessment, which would prevent the risk of differentiated behaviors such as high coding and high sets, and ensure the reasonable use of medical insurance funds. By January 2024, the system had covered 89 ADRG groups, and improved the efficiency and quality of DRG grouping audit. Compared with February to May 2023, the monthly average rejection rate of medical records on the first page decreased by 9.4% after the system was put into operation (June to December 2023), and core medical indicators such as the number of DRG groups, medical insurance settlement cases, and time consumption index continued to improve. The practical experience could provide reference and inspiration for other hospitals in China.
