Outpatient coding guidelines

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The outpatient coding guidelines (AKR) stipulate how diagnoses of outpatients treated in the German healthcare system are to be coded for billing purposes. They are based on the still valid international key system ICD-10-GM (Statistical Classification of Diseases and Related Health Problems, Release 10, German modification), about which they provide explanations on around 160 pages.

scope

From January 1, 2011, the AKR will apply to all doctors, psychological psychotherapists and child and adolescent psychotherapists who bill outpatient and attending medical services at the expense of statutory health insurance. They are binding in both collective and selective contracts . They also apply to outpatient treatment in the hospital for billing purposes. So far, the outpatient operations and ward replacement operations carried out in hospitals in accordance with Section 115b of Book V of the Social Security Code (SGB V) have been excluded . The documentation for medical purposes remains unaffected. The German coding guidelines have been in effect in the inpatient area since 2001 .

Emergence

Doctors and psychotherapists have been obliged to code according to ICD-10-GM since 2000. When applying the ICD-10-GM, there are some ambiguities or room for interpretation that should be resolved with the ASR. The background to this is that the legislature in the GKV Competition Strengthening Act of 2007 tied remuneration in the health care system more closely to morbidity . The financial equalization between the health insurance companies via the health fund is also linked to the morbidity. Accurate data on the incidence of diseases thus gained in importance. They can only be taken from the coded diagnoses. In Section 295 (3) SGB V, the legislature therefore obliged self-administration to specify the coding rules. The institute of the evaluation committee was in charge of drawing up the AKR . In the 3rd quarter of 2010 around 90 doctors and psychotherapists in Bavaria tested the new guidelines (in the 2010 version). They were then revised. In order to make the coding more practicable for general practitioners, the Central Institute for Statutory Health Insurance had a solution by mid-2011.

The AKR (in the 2011 version) should come into force on January 1st, 2011. There was initially a transition phase until June 30, 2011, on which the umbrella association of health insurance companies and the National Association of Statutory Health Insurance Physicians have agreed. In these six months, the outpatient coding guidelines should already be applied, but the health insurance companies should not have submitted any applications for plausibility checks due to coding errors. In a meeting on April 8, 2011, the meeting of representatives of the National Association of Statutory Health Insurance Physicians decided to extend the transition period to January 1, 2012. At the same time it was agreed that the mandatory application should only be prescribed in selected practices. Since the legislature did not follow the decisions of the KBV, the introduction of the outpatient coding guidelines was finally repealed.

construction

The set of rules consists of a general and a special part. The general part contains eleven interdisciplinary guidelines for coding (A01 to A11). The special coding guidelines in Part B are structured analogously to the chapters in ICD-10 and so far contain rules on 61 code areas for selected complex clinical pictures.

Innovations compared to ICD-10

The aim of the new rules is to select the ICD keys as specifically as possible. The special coding guidelines apply before the general ones and these before the rules in the ICD-10-GM itself.

For the first time it is bindingly stipulated what belongs to a treatment diagnosis and what does not: All diagnoses for which the doctor or psychotherapist provides services in the quarter to be billed at the expense of the statutory health insurances or which are related to services provided. Anamnestic diagnoses without benefit reference in the quarter to be billed and incidental findings without further diagnosis or therapy are not to be transmitted. Diagnoses that are treated exclusively by individual health services in the corresponding quarter are also not treatment diagnoses and therefore not to be transmitted.

The AKR are integrated into the software by the manufacturers of the practice management systems and can be displayed there. The software continuously checks whether the diagnoses match each other and with the billing codes. An error message indicates when a position from the Uniform Assessment Standard requires a certain ICD code. In the event of minor discrepancies, such as unsuitable additional identifiers, the software issues a notification. These auxiliary functions are not automatically active in the transition phase.

A transfer of diagnoses from the previous quarter, also in the case of permanent diagnoses, may only take place if they meet the criteria of a treatment diagnosis, i.e. H. Have caused or are related to services. In the practice software, the regular treatment-relevant diagnoses and the anamnestic diagnoses can be marked for each patient. In a new quarter, the treatment-relevant diagnoses can be adopted en bloc, individual ones deselected or others added.

Suspension of the outpatient coding guidelines with effect from July 1, 2011

According to the cabinet draft of the Statutory Health Insurance Supply Structure Act (as of August 3, 2011), the statutory obligation under Section 295, Paragraph 3, Clause 2 of Book V of the Social Code to agree on outpatient coding guidelines (AKR) is to be deleted. This is justified with the aim of reducing excessive regulation in the remuneration system of statutory health insurance physicians. This was preceded by broad resistance from the medical community to the AKR. In order to take into account the foreseeable new legal regulation, the partners of the federal shell contracts have agreed to suspend the introduction of the AKR originally planned for July 1, 2011. In this context, the partners of the federal shell contracts jointly state that without the AKR, comprehensive quality assurance of the diagnoses in 2011 and in the following years cannot be achieved.

Individual evidence

  1. ↑ a b Introduction of the outpatient coding guidelines canceled Press release of the Association of Statutory Health Insurance Physicians in Berlin, accessed on March 6, 2019
  2. ↑ National Association of Statutory Health Insurance Physicians : Outpatient coding guidelines: No application as of July 1, 2011 (PDF) Retrieved on November 1, 2011.

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