椎板回植术的ICD-9-CM-3编码探讨  

Lamina Replantation's ICD-9-CM-3 Coding Research

作　　者：李仕林[1] 陈立兵[1] 赵艳[1] 叶婉茵 LI Shi-lin;CHEN Li-bing;ZHAO Yan;YE Wan-yin(Case Room, Department of Quality Control, Yuebei People.s Hosptial,Guangdong Shaoguan 512026)

机构地区：[1]广东省韶关市粤北人民医院质控科病案室,广东韶关512026

出　　处：《中国医疗器械信息》2017年第15期115-116,共2页China Medical Device Information

摘　　要：目的:探讨胸腰椎板回植术准确的ICD-9-CM-3编码。方法:以2014年1月~2016年12月来本院就诊的40例椎管内肿瘤患者的病案为研究对象,并详细研究其中12例行肿瘤切除+椎板回植术(后路)患者的病案。首先与临床医生进行沟通,然后查阅工具书和文献,再在高年资编码员主持下进行科内讨论,最后确定该手术的编码。结果:椎板回植术(后路)准确的ICD-9-CM-3编码为78.09。结论:在对临床新开展手术操作编码的之前,应该将患者的病历进行深入分析,并与临床医生沟通,再查阅文献资料,在资深编码员主持下进行详细讨论,最后才能确定编码。在给予ICD-9-CM-3字典库临时编码字段的时候,应考虑与临床医生的书写习惯相结合。Objective:To research lamina replantation’s accurate ICD-9-CM-3coding.Methods:40cases of spinal canal tumor from January2014to December2016inour hospital were analyzed.Made detail researched at12case of which performed tumor resection and lamina replantation.Communicated with the clinicaldoctor,refer to documents and tool books,made a detail discussion which directed by senior coder,before made accurate coding of the operation.Results:The accurate ICD-9-CM-3coding of lumbar lamina replantation is78.09.Conclusion:Before coding the newly-commenced operation,made a deep researchof the medical case,communicated with the clinical doctor,refer to documents,and made detail discussion with senior coder.Considered with the doctor’shandwriting habit when appended the temporary code field of the newly-commenced operation in the ICD-9-CM-3dictionary.

关 键 词：ICD-9-CM-3编码 椎管内肿瘤 椎板回植术 新开展手术 临时编码 

分 类 号：R687.3[医药卫生—骨科学]