陈旧性骨折ICD-10编码探讨  

Exploration of coding in ICD-IO for old fracture

作　　者：江惠婷[1] 申放[1] 汪满仙[1] 杨延斌[1] 

机构地区：[1]佛山市中医院病案统计室,广东省佛山市528000

出　　处：《中国医院统计》2012年第5期349-351,共3页Chinese Journal of Hospital Statistics

基　　金：佛山市医学科技攻关项目（201008002）

摘　　要：目的提供规范标准的疾病诊断名称和ICD-10编码字典库，满足临床查询检索，满足“相关疾病诊断分组（DRGs）”病种医疗费用管理，医院HIS系统和区域卫生信息化建设的需求。方法分析疾病诊断陈旧性骨折在临床医学中的定义，在国际疾病分类ICD-10中的含义和国际疾病分类（ICD-10）编码原则。结果临床医生所诊断的陈旧性骨折疾病是指外伤骨折2～3周以后就诊的病人。在ICD-10中，陈旧性骨折被分类到损伤、中毒和外因的其他后果的后遗症（T90-T98）。T90-T98类目是用于表明在类目S00-S99和T00—T88中的情况是晚期效应的原因，即在急性损伤后-年或更长时间仍然存在的那些情况。按ICD分类原则，外伤后2～3周至一年以内就诊的临床诊断陈旧性骨折应分类于S00-S99和T00—T88各相应的骨折类目中，但编码后ICD-10数据库对应的诊断名称是没有修饰词“陈旧性”的骨折病名，造成临床诊断病名和疾病分类病名不-致。要将这类陈旧性骨折与新鲜骨折区分开来，本文建议在S00-S99和T00—T88的有关骨折的类目中增加细目编码“2”，作为损伤一年以内陈旧性骨折的疾病分类编码。结论根据ICD原则，通过增加必要的细目编码，使ICD-10疾病分类病名与临床诊断病名一致，以得到临床医师的认可和使用并起到规范疾病名称的作用。按DRGs组合方式制订病种住院费用标准，必须建立在医疗卫生信息标准化的基础上。Objective To provide a standardized disease name and ICD-10 coding base for clinical searching, and fulfil the need of the Diagnosis Related Groups （DRGs） medical cost management system, the HIS system of hospitals, and the region- al hygienic information system. Methods Analyzing the definition of diagnosing old fractures in clinical medicine,and analyzing the meaning of ICD-10 in international disease classification and the coding principles of ICD-10 in international disease classification. Results Old fractures refer to the bone injuries suffered by the patients who receive medical attention two to three weeks after the injuries are done. In ICD-10, old fracture is classified as the sequelae of damage, poisoning and other external causes of injuries （ T90-T98 ）. The classification of T90-T98 generally refers to late effects from the injuries of categories S00-S99 and TOO- T88, meaning the effects lasting for a year or longer after the injuries. According to the principles of ICD classification system, fracture patients who go to the hospital from two or three weeks to a year after being injured should be classified as S00-S99 and T00-T88 respectively. However, there is not an ＂old＂ term in fractures in the ICD-10 database, causing inconsistency in names in＇ clinical diagnosis and classification system. To separate old fractures from the new ones, the code of 2 should be added to the sub-categories of S00-S99 and T00-T88 as reference to old fractures made within one year. Conclusion According to the principles of ICD classification system, sub-categories, widely recognized by clinical doctors and serving as a standardization, should be added to existing classification system to match the names of the ICD-10 system and clinical diagnosis. We formulate hospitalization expense standard of each disease according to the diseases in the DRGs combination, should be based on medical and hygienic information standardization.

关 键 词：陈旧性骨折 ICD-10 编码 

分 类 号：R197.323[医药卫生—卫生事业管理]