Leistungserfassung - Activity recording for billing in Germany

General workflow

Capture

The capture of data regarding delivered services is done at the time of delivery by the person responsible for the delivery (e.g. a nurse, a radiologist or medical therapist).

Coding

Depending on the usage, the provisioning of services in the hospital is coded in different ways:

DRG coding: For operational and other procedures which are carried out for inpatients or outpatients in the hospital, OPS codes are usually used;

Billing of single services: Depending on the health insurance type different tariff systems are used e.g. uniform assessment standard (EBM) or the tariff system for physicians (GOÄ);

In-house accounting for services: Here both OPS and tariff systems (GOÄ or EBM) can be used. The advantage of the tariff systems is that a provisioning is already assigned to a cost equivalent (point values). Thus tariff systems are also used with the DRG calculation to the capture of the expenses.

Ideally, a uniform mechanism based on an internal catalog should be made available for the coding of delivered services. Nevertheless, because of the complicated rules involved (e.g. guidelines for DRG-coding) it is only possible in limited cases.

Grouping

At the time of the coding, all data relevant for DRG are usually not available yet or not yet provided by the software interfaces.

Example: When a patient is discharged, the completeness and correctness of the documentation is checked. The data required for the determination of a DRG, among other things the diagnoses of the patient (coded using ICD-10) as well as the procedures (coded with OPS), are displayed and valued.

Communication

Message overview

To support billing, two HL7 message types are used in Germany:

• BAR messages to transfer information regarding diagnosis codes and procedures: used for DRG i.e. procedure based fees.

• DFT messages are used for lump compensation and additional/extra fees, to transfer:
• either EBM/GOÄ codes if the sending system supports a rule based generation of EBM and GOÄ codes
• or neutral charge codes if not 

DFT Messages

Statutory basis

Vertragsarztrechtsänderungsgesetz

The Vertragsarztrechtsänderungsgesetz (German law regarding physicians involved in contractual medical care) was considerably liberalized the activities of physicians on January, 1st 2007). It considerably changed how physicians can be contracted (e.g. part time) and how practices can be organized.

Therefore, all active physicians involved in contractual medical care received on July, 1st 2008 a new lifelong doctor's number and a company site number, so that their performed services can be associated unambiguously to an insurance company.

Starting July, 1st 2008, every physicians involved in contractual medical care must mark all bills with the LANR (lifelong doctor's number) and the BSNR (company site number). Thus all DFT messages should contain this information.

LANR

The lifelong doctor's number (LANR) refers to the person. All active physicians involved in contractual medical care country-wide have been given such a 9 digit number.

The first 7 digits of the LANR are assigned to a physician once and never change.

The 8th and 9th digits of the LANR encode the specialty of the physician. They can change if the doctor changes his main activity focus.

BSNR

The company site number (BSNR) indicates whether the doctor has performed an activity at his main site or at satellite site. Every hospital/practice main or satellite site as well as every medical care center receives its own number.

The company site number is necessary for all bills instead of the previously used doctor's number. The physicians involved in contractual medical care can present a common bill for all activities to the insurance company. Then the bill must contain the different company site numbers.

BAR Messages


Diagnosis and procedures

Diagnosis codes are to be coded using ICD-10.
Procedure codes are to be coded using OPS (formerly known as OPS-301).

Both catalogs of codes are updated every year. The new catalogs have to be made available in all systems (HIS and departmental systems) at the same time. It must be possible to import the published list of procedure/diagnosis codes in the OIS.
Additionally all codes sent in BAR messages have to be assigned a code representing the catalog used for the coding (e.g. I10-2009 or O301-2009).

Each diagnosis code or procedure code must be uniquely identified in BAR messages.

When diagnosis codes and/or procedure codes are cancelled, a cancellation BAR message is to be sent with all codes having been cancelled.

When diagnosis codes and/or procedure codes are updated, an update BAR message is to be sent with all codes having been updated.