Effects of computer-assisted documentation in orthopedic surgery on budgetand reimbursement

Since 1995 German health maintenance laws require hospitals to document and code all referals, admissions and discharges using the 4-digit ICD. Operat ive procedures are documented and coded using the ICPM. Beginning in Januar y 1996, reimbursement for health services requires a diagnosis-related bill ing and payment for special procedures. The decision for billing is based o n documented diagnosis and thera py. This extended request for documentatio n makes an online access to diagnosis and therapy with a computer-assisted coding system advisable. In 1996 in our hospital each diagnosis and operati on was manually documented and coded on a form. Since the beginning of 1997 , documentation and coding has been exclusively computer-assisted. On the b asis of documented diagnosis and therapy the computer provides the route of reimbursement. Retrospectively we evaluated the number of charged diagnosi s-related billings and payments for special procedures from January to Apri l of 1996 and 1997. It became evident that with computer-assisted documenta tion and coding the number of detected and charged diagnosis-related billin gs and payments for special procedures was significantly increased in compa rison with the previous year.