A statistical analysis of ‘rule-out’ diagnoses in outpatient health insurance claims in Japan

Tanihara, Shinichi; Okamoto, Eiji; Une, Hiroshi

doi:10.1111/j.1365-2753.2010.01482.x

Cited by 16 publications

(19 citation statements)

References 8 publications

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“…Japan's health insurance system of fee‐for‐service reimbursement dictates that each clinical procedure be justified by a corresponding diagnosis. In addition, an unconfirmed or disproved diagnosis might appear on the claim as a tentative or ‘rule out’ diagnosis . However, CP diagnosis is unlikely to be tentative because most pediatricians are very cautious to avoid labeling those children without CP as having this condition.…”

Section: Discussionmentioning

confidence: 99%

Estimation of the number of children with cerebral palsy using nationwide health insurance claims data in Japan

Toyokawa

Maeda

Kobayashi

2016

Develop Med Child Neuro

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Section: Discussionmentioning

confidence: 99%

Estimation of the number of children with cerebral palsy using nationwide health insurance claims data in Japan

Toyokawa

Maeda

Kobayashi

2016

Develop Med Child Neuro

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“…In Japan, HICs contain not only confirmed diagnoses but also unconfirmed or disproved diagnoses, because each clinical procedure must be justified by a corresponding diagnosis; as a result, rule-out diagnoses are included in the HICs to ensure reimbursement for these clinical procedures, even when the results show that the suspected diseases are not present. 20 , 21 Assessment of the validity of diagnoses described on HICs and accuracy of coding for the diagnoses on HICs in Japan awaits further investigation.…”

Section: Discussionmentioning

confidence: 99%

The Proportion of Uncoded Diagnoses in Computerized Health Insurance Claims in Japan in May 2010 According to ICD-10 Disease Categories

Tanihara

2014

Journal of Epidemiology

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BackgroundUncoded diagnoses in computerized health insurance claims are excluded from statistical summaries of health-related risks and other factors. The effects of these uncoded diagnoses, coded according to ICD-10 disease categories, have not been investigated to date in Japan.MethodsI obtained all computerized health insurance claims (outpatient medical care, inpatient medical care, and diagnosis procedure-combination per-diem payment system [DPC/PDPS] claims) submitted to the National Health Insurance Organization of Kumamoto Prefecture in May 2010. These were classified according to the disease categories of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). I used accompanying text documentation related to the uncoded diagnoses to classify these diagnoses. Using these classifications, I calculated the proportion of uncoded diagnoses by ICD-10 category.ResultsThe number of analyzed diagnoses was 3 804 246, with uncoded diagnoses accounting for 9.6% of the total. The proportion of uncoded diagnoses in claims for outpatient medical care, inpatient medical care, and DPC/PDPS were 9.3%, 10.9%, and 14.2%, respectively. Among the diagnoses, Congenital malformations, deformations, and chromosomal abnormalities had the highest proportion of uncoded diagnoses (19.3%), and Diseases of the respiratory system had the lowest proportion of uncoded diagnoses (4.7%).ConclusionsThe proportion of uncoded diagnoses differed by the type of health insurance claim and disease category. These findings indicate that Japanese health statistics computed using computerized health insurance claims might be biased by the exclusion of uncoded diagnoses.

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“…Rule-out diagnoses account for a considerable portion of diagnoses contained in health insurance claims, and many are recorded to justify reimbursement. 23 Although diagnoses contained in health insurance claims are not free from bias, PDM analysis that excludes rule-out diagnoses is far more accurate than classification by principal diagnoses. 24 …”

Section: Discussionmentioning

confidence: 99%

Effects of Health Guidance on Outpatient and Pharmacy Expenditures: A Disease- and Drug-Specific 3-Year Observational Study Using Propensity-Score Matching

Okamoto¹

2013

Journal of Epidemiology

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BackgroundEvidence is lacking on whether health guidance for metabolic syndrome reduces health care expenditures. The author used propensity-score matching to evaluate the effects of health guidance on health care expenditure.MethodsMen who did and did not receive health guidance from a health insurance society (approximately 60 000 covered lives) were matched (n = 397 respectively) using propensity scores. Health insurance claims were compared using cumulative health care expenditures for metabolic syndrome-related outpatient medical care and drug costs for the period from the initial consultation to 3 years later.ResultsNo difference was observed between intervention and control groups in cumulative outpatient charges or drug costs related to metabolic syndrome. However, regression analysis using the Tobit model showed that health guidance resulted in a small, nonsignificant reduction in health care expenditure.ConclusionsHealth guidance for metabolic syndrome did not reduce outpatient charges or drug costs related to metabolic syndrome during the 3-year period after the intervention. Findings from Tobit regression suggest that health guidance might eventually result in savings, but this hypothesis remains untested.

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A statistical analysis of ‘rule-out’ diagnoses in outpatient health insurance claims in Japan

Abstract: The existence of rule-out diagnoses affects the results of statistics based on HIC data. Japanese statistics based on HIC data should be improved by utilizing the information on rule-out diagnoses.

Cited by 16 publications

References 8 publications

Estimation of the number of children with cerebral palsy using nationwide health insurance claims data in Japan

Estimation of the number of children with cerebral palsy using nationwide health insurance claims data in Japan

The Proportion of Uncoded Diagnoses in Computerized Health Insurance Claims in Japan in May 2010 According to ICD-10 Disease Categories

Effects of Health Guidance on Outpatient and Pharmacy Expenditures: A Disease- and Drug-Specific 3-Year Observational Study Using Propensity-Score Matching

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