What are the new changes after the revision, and what points should be paid attention to when reporting the medical insurance settlement list? This article will explain it for you.

Recently, in order to further improve the data quality of medical insurance settlement list and accelerate the comprehensive application of medical insurance settlement list, according to the requirements of the Notice of the Office of the State Medical Insurance Bureau on Implementing 15 Medical Insurance Information Business Coding Standard (No.51No.2020) and other documents, combined with the actual situation in the application area, the State Medical Insurance Bureau carried out the medical insurance fund settlement list (No.20650).

What are the new changes after the revision, and what points should be paid attention to when reporting the medical insurance settlement list, for your interpretation:

0 1

List style change

02

Basic information change

1. Article 2 of the revised Basic Information of the Standard: The data index of medical insurance settlement list is 193 (original 190), of which the basic information part is 3 1 (original 32), the outpatient information part of chronic diseases and special diseases is 6, and the inpatient information part is 58 (original)

2. In Article 4 of the basic information of the revised code, the "medical outpatient bill" is added, corresponding to the new chronic diseases and special diseases in outpatient service;

3. Article 5 of the basic information of the revised version of the Code adds the content of "Code of chronic diseases and special diseases in outpatient clinics using medical insurance outpatient chronic diseases and special diseases".

4. In Article 7 of the revised Code Basic Information, delete "all data indicators marked with" * ",and emphasize that" all items are required data indicators, some are required, and others are empty ".

5. Article 9 is added to the basic information of the revised Code: outpatients with chronic diseases and special diseases do not need to fill in "hospitalization information" and inpatients do not need to fill in "outpatient treatment information for chronic diseases and special diseases".

6. Article 10 of the basic information of the revised Code is added: requirements for inventory storage. Medical insurance departments and medical institutions should properly keep the settlement list. In order to ensure the objectivity, authenticity and legal effect of the list, according to the Electronic Signature Law of People's Republic of China (PRC), the Notice on Standardizing the Filing of Reimbursement Electronic Bookkeeping Vouchers (Caishuizi [2020] No.6) and the Decision of the Ministry of Finance on Modification (CaishuiziNo. 104), the list can be stored and kept in the form of electronic settlement list after being signed and reliably filed. At the same time,

03

Data acquisition standard change

(1) Basic information data indicators.

1. serial number: added "the setting of serial number means that each designated medical institution generates a serial number separately." Description of;

2. Name of designated medical institution: the name of the institution registered according to the legal person certificate or business license of the institution.

3. Code of designated medical institutions: the original "unique identification code of designated medical institutions for patients in the classification and code database of designated medical institutions for medical security" was changed to "institutional code obtained on the platform of" Dynamic Maintenance of Medical Insurance Business Coding Standards "of National Medical Insurance Bureau".

4. Medical insurance settlement level: it is clearly defined as "the charging level of designated medical institutions in the medical insurance management information data subset, which is divided into level 1, level 2 and level 3."

12. If the age is less than 1 year, the age shall be determined according to the age of days.

26. Types of medical insurance: According to the national medical insurance policy, the types of medical insurance are (1) basic medical insurance for employees, (2) basic medical insurance for urban and rural residents, and (3) other medical insurance (according to the relevant national or local security policies, such as the Decision of the State Council on Establishing the Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No.44).

27. Special personnel types: insured persons receiving medical assistance: (1) extremely poor persons (2) low-income households, (3) people returning to poverty, and (4) other people in difficulty (supplemented by other types of people in difficulty stipulated by local governments according to local security policies).

29. Newborn admission type: Add "If there are two or more cases, you can choose more than one." describe

30. Birth weight of newborn (g): Add the description of multiple births "If it is multiple births, separate it with commas"; Add "the above-mentioned newborn refers to the baby born to 28 days, and the birthday is the 0 th day." Description.

(two) outpatient chronic disease diagnosis and treatment information data indicators.

3. Disease name: the unified disease name obtained by the local medical insurance department through the "Dynamic Maintenance of Medical Insurance Business Coding Standards" platform of the National Medical Insurance Bureau, which is used to maintain chronic diseases and special diseases in local outpatient clinics.

4. Disease code: the unified disease code obtained by the local medical insurance department through the "Dynamic Maintenance of Medical Insurance Business Code Standard" platform of the National Medical Insurance Bureau is used to maintain chronic diseases and special diseases in local outpatient clinics.

(3) Data index of hospitalization information.

17. Operator's physician code: the medical insurance physician code obtained by designated medical institutions on the platform of "Dynamic Maintenance of Medical Insurance Business Coding Standards" of National Medical Insurance Bureau.

19. Anesthesiologist code: the medical insurance physician code obtained by designated medical institutions on the platform of "Dynamic Maintenance of Medical Insurance Business Coding Standards" of the National Medical Insurance Bureau.

20. Start and end time of operation and operation: The start time of operation refers to the time when the surgeon officially starts the operation (that is, "the knife touches the skin"); The end time of operation refers to the time for the surgeon to complete all operations.

2 1. Start and end time of anesthesia: the start time of anesthesia refers to the time when the anesthesiologist formally implements anesthesia (general anesthesia refers to the start of anesthesia induction and local anesthesia refers to the start of drug injection); The end time of anesthesia refers to the time to leave the operating room after the operation.

25.ICU type *: add "(7)ICU (general)".

28.Total (_ hours _ minutes): the original "total hours".

3 1. Blood transfusion unit of measurement: the unit of measurement for each blood component to be given to the patient. Please refer to the blood transfusion variety code table (CV). And attach a specific code table.

36. Attending physician code *: The medical insurance physician code obtained by designated medical institutions on the platform of "Dynamic Maintenance of Medical Insurance Business Coding Standards" of the National Medical Insurance Bureau.

37. Name of the responsible nurse: the responsible nurse who is responsible for the overall care of the patient in the department where the responsibility system is implemented.

38. Responsible nurse code: the medical insurance nurse code obtained by designated medical institutions on the platform of "Dynamic Maintenance of Medical Insurance Business Coding Standards" of the National Medical Insurance Bureau.

(four) medical fee information data indicators.

5. Total amount: The item of total amount emphasizes "daytime operation fee and single disease fee" separately. The report caliber is filled in according to the medical service classification and code (see Note 4 for the report caliber). The original report caliber is downloaded separately.

6. "XX (charging name+coding by disease type)": newly added, it refers to charging patients by disease type (such as single disease type and daytime operation). In principle, patients who pay by disease type do not need to fill in 14 "bed fee, examination fee, inspection fee, laboratory fee, treatment fee, operation fee, nursing fee, sanitary material fee, western medicine fee, Chinese medicine decoction pieces fee, Chinese patent medicine fee, general medical treatment fee, registration fee and other fees".

7. Payment of supplementary medical insurance: The medical expenses borne by the individual shall be guaranteed, except for the basic medical insurance for patients, which conforms to the relevant provisions of social insurance.

Large subsidies for employees (including serious illness insurance for employees in some provinces): to further protect the high medical expenses incurred by insured employees who meet the requirements.

Residents' serious illness insurance: further protect the high medical expenses incurred by residents' medical insurance insured patients.

10. Personal burden: The amount paid by the enterprise supplementary fund in accordance with the relevant regulations when the insured persons participating in employee medical insurance and urban and rural residents' medical insurance purchase medicines at outpatient clinics, hospitals and pharmacies can be divided into individual self-payment and individual self-payment.

Personal self-payment: the amount of medical expenses incurred by the patient in this diagnosis and treatment within the scope of the basic medical insurance catalogue, (personal self-payment = deductible line+first self-payment+proportional self-payment+capping line, including the over-limit part in the catalogue and the compensation part of the second reimbursement fund during the treatment transition period), and the expenses paid by the patient in a fixed way according to the disease type, disease type and bed day.

Personal expenses: The medical expenses incurred by the patient in this medical treatment are all paid by the individual, which is not included in the basic medical insurance catalogue according to relevant regulations.

165438+

12. Personal payment: The medical expenses actually paid by the individual for this medical treatment are divided into personal account payment and personal cash payment.

(1) Personal account payment: used to pay out-of-pocket expenses of the insured within the policy scope of designated medical institutions).

(2) Personal cash payment: the amount paid by individuals through cash, bank cards, WeChat, Alipay and other channels.

The relationship between the above items: total amount = medical insurance pooling fund payment+supplementary medical insurance payment+medical assistance payment+personal burden; Personal burden = other contributions+personal contributions.

Source: There are several doctors.