Ortner's综合征的ICD-10编码探讨  

Discussion on the ICD-10 Coding of Ortner's Syndrome

作　　者：吴丽娟 朱文俊[2] 徐敏慧[1] 郑盼 郭佳奕[1] Wu Lijuan;Zhu Wenjun;Xu Minhui;Zheng Pan;Guo Jiayi(Jinhua Municipal Central Hospital, Jinliua 321000, Zhejiang Province, China)

机构地区：[1]浙江省金华市中心医院,浙江省金华市321000 [2]浙江大学医学院附属妇产科医院,浙江省杭州市310000

出　　处：《中国病案》2019年第4期29-31,共3页Chinese Medical Record

摘　　要：Ortner's综合征系心血管疾病压迫左侧喉返神经引起左侧声带麻痹,导致声音嘶哑等症状的一组综合征。通过查阅相关资料、沟通临床医师,深入学习Ortner's综合征的病因、疾病性质等临床知识,遵循ICD-10分类原则,选择和变通主导词,最终以"麻痹-喉神经"查得Ortner's综合征编码为J38.0。同时列举几份典型病例,准确分类Ortner's综合征。罕见综合征的分类工作较为复杂,要加强学习、积极沟通临床,熟悉疾病的命名、病因和临床表现,正确选择主要诊断,为扎实推进医保DRGs付费改革提供数据支撑。Ortner’s Syndrome is a group of syndromes in which cardiovascular diseases oppress the left recurrent laryngeal nerve and cause left vocal cord paralysis, resulting in hoarseness and other symptoms. To consult relevant materials, communicate with clinicians, and study the clinical knowledge of the etiology and nature of Ortner’s Syndrome in-depth, then follow the ICD-10 classification principles, select and modify the dominant words, finally obtain its coding as J38.0 with "paralysis-laryngeal nerve". Simultaneously through enumerating several typical cases to classify Ortner’s Syndrome accurately. The classification of rare syndrome is much more complicated. We should strengthen learning and communicate with clinical doctors actively, so as to master the name alias, etiology and clinical manifestation of the disease,thereby select the major diagnosis correctly, ultimately to provide data support for the reform of medical insurance payment methods.

关 键 词：Ortner's综合征 声带麻痹 ICD-10 

分 类 号：R197.323[医药卫生—卫生事业管理]