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.