某院乳腺癌手术编码审核前后对比分析  

Comparative Analysis before and after the Code Review of Breast Cancer Surgery in a Hospital

作　　者：孙鹏[1] Sun Peng(Department of Medical Records, Beijing Tongren Hospital Affiliated to Capital Medical Records, Beijing 100730, China)

机构地区：[1]首都医科大学附属北京同仁医院病案科

出　　处：《中国病案》2019年第7期27-29,共3页Chinese Medical Record

摘　　要：目的分析某院2018年乳腺癌手术病例的手术编码情况,以及审核前后DRGs分组的情况,从而提高编码质量。方法利用病案信息查询系统调取某院2018年主要诊断为乳腺癌,主要手术编码(ICD-9-CM-3)为85.2~85.4的病例共161例,利用前后对比及图表对照的方式进行分析。结果 161例病例中编码错误63例,错误率为39%。错误的编码将手术分类到了高的DRGs组别,影响医保的付费以及手术的真实性。结论通过对错误编码的总结和分析,编码错误的原因主要在于编码员对临床知识的欠缺,以及临床医师书写手术名称不规范,遇到问题时编码员需及时向临床医师沟通,同时提高医师书写病历质量。Objectives To analyze the surgical coding of the 2018 breast cancer surgery records in a hospital,as well as the situation of DRGs grouping before and after the audit, so as to improve the coding quality. Methods Using the medical record information inquiry system, a total of 161 cases of breast cancer with a major surgical code(ICD-9-CM-3) of 85.2-~85.4 were collected from a hospital in 2018, using the comparison before and after comparison and chart comparison to make an analysis. Results There were 63 coding errors in 161 medical records, and the error rate was 39%. Wrong coding classifies surgery into high DRGs, affecting the cost of health care and the authenticity of the surgery. Conclusions Based on the summary and analysis of error coding, the main causes of coding errors lie in the lack of clinical knowledge of the coder and the irregularity of the operation name written by the clinician. In order to improve the coding quality and ensure the accuracy of DRGs grouping,the coder should communicate with the clinician in time when encountering problems, and improve the quality of the medical record written by the physician.

关 键 词：乳腺癌 手术编码 DRGs分组 

分 类 号：R737.9[医药卫生—肿瘤]