微创腰椎融合术的ICD-9-CM-3编码探讨  

ICD-9-CM-3 Code of Minimal Invasive Lumbar Interbody Fusion Surgery

作　　者：陈合辉[1] 陈秋燕[1] 

机构地区：[1]广东省广州市中山大学附属第三医院,广州市510630

出　　处：《中国病案》2012年第4期44-45,共2页Chinese Medical Record

摘　　要：微创腰椎融合术术式繁多,椎管减压和腰椎融合容易出现编码错误。原因有医师书写手术名称不规范和编码人员对手术知识不了解。因此在对此类手术进行编码时,要多查阅脊柱融合的相关手术知识;多与临床医师沟通,规范手术名称的书写,进一步了解手术实施的步骤和最新的进展;详细查阅手术记录,确定微创术式、椎管减压的类型及融合椎骨的数目,并结合手术材料清单,判断是否应用了椎间融合器或植入椎间物质,这样才能做出准确编码,为临床医、教、研提供最具价值的病案信息。There are many kinds of minimally invasive lumbar fusion procedure, and decompression and lumbar fusion prone to coding errors.The reason consists of unstandardized write of the surgical procedure by doctor and not understanding the surgical knowledge by coders.The knowledge of spinal fusion surgery should be searched during coding,and do more communication with clinicians so that the writing of the surgery name be write much more standardized.The surgical implementation steps and the latest progress should be learned.The accurate coding can be made by detailed access to the surgery record,determine the number of minimally invasive surgical procedures,the type of decompression and fusion of vertebrae,and determine whether the application of the interbody fusion device or implanted in the intervertebral substances so that to provide the most value medical record information for clinical medicine,teaching and research.

关 键 词：微创腰椎融合术 ICD-9-CM-3 编码 

分 类 号：R687.3[医药卫生—骨科学]