卵巢肿瘤疑难编码解析  

Analysis on the Difficult Coding of Ovarian Tumor

作　　者：马艳玲[1] 

机构地区：[1]首都医科大学附属北京妇产医院病案科,北京市100006

出　　处：《中国病案》2013年第8期26-27,共2页Chinese Medical Record

摘　　要：卵巢肿瘤的ICD-10编码较难,容易产生编码错误。例如卵巢颗粒细胞瘤,若以"瘤"为主导词在ICD-10卷三中查"颗粒细胞"这一修饰词得到的是错误编码;卵巢类固醇细胞瘤,根本无法直接从ICD-10卷三中查到编码,需变换修饰词;卵巢皮样囊肿,由于其疾病名称中无"瘤"字,则易使编码员误按卵巢囊肿进行分类。通过对日常工作中所积累的较疑难的卵巢肿瘤编码进行分析与归类,总结出导致其编码错误的主要原因在于编码员医学知识匮乏,对其所分类的疾病缺乏认识。建议编码员在进行疾病分类时除熟练掌握编码原则外,还要积极补充医学知识,要做到在确保对疾病有全面了解的基础上进行分类,才能提高编码准确率。The coding of ovarian tumor in ICD-10 is relatively difficult and it is easy to generate coding errors. Take ovarian granulosa edl tumor as an example, if we investigate ＂granulosa cells＂ as the qualifier by choosing the terms of ＂tumor＂ as the leading word in the ICD-10 Volume 1II, it will get the error code. When we search ovarian steroid cell tumor, it will not found from the ICD-10 Volume III directly and we must transform modifier . Another example is ovarian dermoid cyst, as its name is not include the word of ＂tumor＂, it is easy to make the mistake coders classified by ovarian cysts. Through the analysis and classification of relatively difficult coding of the ovarian tumors we aceumulated daily work, we concluded that the main reason of wrong coding was the medical knowledge deficinece of coders and their lackness of understanding to the classification of the disease. Therefore, we recommended that the coders must replenish medical knowledge besides mastering the coding principles skillfully to ensure a comprehensive under- standing of the disease, then we can expect to improve the coding accuracy.

关 键 词：国际疾病分类 卵巢肿瘤 疑难编码 

分 类 号：R737.31[医药卫生—肿瘤]