COMPUTERIZED PREANESTHETIC EVALUATION RESULTS IN ADDITIONAL ABSTRACTED COMORBIDITY DIAGNOSES

Objective. To study the impact of information from a physician-entry c omputerized preanesthetic evaluation system on the coding of Internati onal Classification of Diseases (ICD-9-CM) diagnoses and on hospital r eimbursement due to alterations in diagnosis-related group (DRG) codes . Methods. Nonrandomized, unblinded trial conducted at a 570-bed unive rsity tertiary care hospital. First without and then with reference to information contained on computer-based preanesthetic evaluation repo rts, medical charts were coded by the study institution's usual profes sional coders for ICD-9-CM discharge diagnoses and DRG assignment. Res ults, For 22 of 180 charts studied (12%, 95% confidence limits 7.4% to 16.7%), at least one ICD-9-CM diagnosis was added. Three of 84 DRG-ba sed reimbursements were altered, increasing hospital reimbursement by 1.5%. Conclusions. Supplemental information from a physician-entered, problem-oriented, computerized preanesthetic evaluation system improve d discovery of diagnoses in the population studied.