Computerized pre-anesthetic evaluation results in additional abstracted comorbidity diagnoses

Objective. To study the impact of information from a physician-entry computerized preanesthetic evaluation system on the coding of International Classification of Diseases (ICD-9-CM) diagnoses and on hospital reimbursement due to alterations in diagnosis-related group (DRG) codes. Methods. Nonrandomized, unblinded trial conducted at a 570-bed university tertiary care hospital. First without and then with reference to information contained on computer-based preanesthetic evaluation reports, medical charts were coded by the study institution's usual professional coders for ICD-9-CM discharge diagnoses and DRG assignment. Results, 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-based reimbursements were altered, increasing hospital reimbursement by 1.5%. Conclusions. Supplemental information from a physician-entered, problem-oriented, computerized preanesthetic evaluation system improved discovery of diagnoses in the population studied.