COMPUTER-ASSISTED CODING OF ICD-9 10 AND ICPM CODING ACCORDING TO GERMAN LAW - SOLUTION FOR TRAUMATOLOGY AND ORTHOPEDICS/

From the beginning of 1995, the German law on the health system struct ure prescribes that in all clinics the four-digit ICD code be supplied for each diagnosis and the ICPM code for each operation. This makes o n-line access to diagnosis and therapy codes embedded in a clinic docu mentation system advisable. Since 1 February 1995, in one department o f traumatologic surgery the ICD diagnosis and ICPM therapy coding is m anaged on-line by the doctors in the outpatient clinic and operation t heatre, using the ''do it'' coding system in combination with the KAUZ system for clinic documentation. The user guidance supplied by a freq uency-oriented menu and specialist traumatological terms makes it poss ible to determine the ICD and ICPM codes without any great expenditure of effort. Furthermore, the appropriate flat rates per case and speci al charges are displayed. Comparison of manual and computer-assisted c oding of operations during 1 month (160 patients, 173 operations) show ed that manual coding could be corrected or improved by the computeriz ed system in 35% of cases. The ICD-10 system has already been integrat ed: it improves the recording of diagnoses and will simplify the chang e over to the coming new revision.