神经鞘瘤的疾病与手术编码案例分析  

Case analysis of disease and surgery coding for schwannoma

作　　者：陈芳 郭佳奕[1] 袁坚列[1] 徐敏慧[1] 郑盼 吴丽娟 刘继红[1] Chen Fang;Guo Jiayi;Yuan Jianlie;Xu Minhui;Zheng Pan;Wu Lijuan;Liu Jihong(Jinhua Central Hospital,Jinhua 321000,China)

机构地区：[1]金华市中心医院,浙江金华321000

出　　处：《中国医院统计》2020年第1期91-93,96,共4页Chinese Journal of Hospital Statistics

基　　金：浙江省重点研发计划项目(2019C03044)。

摘　　要：神经鞘瘤是发生于周围神经和中枢神经的良性肿瘤,属于神经肿瘤。由于编码人员的临床医学知识不足,对神经鞘瘤的疾病类型和手术方式不够熟悉,过于依赖计算机编码,以及编码制度中缺乏编码复核质控等原因,导致编码工作中常会发生将神经鞘瘤错误编码为疾病发生部位的良性肿瘤。本文介绍了神经鞘瘤的临床特征及其疾病和手术编码,同时通过3例神经鞘瘤典型病例的回顾性研究,分析编码错误的原因,总结了神经鞘瘤编码思路。医疗机构应当重视编码工作,不断提升编码员的业务能力和责任心,并通过设立专科编码员,建立病案首页的编码复核等机制来提高疾病及手术编码的正确率。Schwannoma is a benign tumor of peripheral and central nerves,which belongs to the nerve tumors.Due to the lack of clinical medical knowledge,the lack of familiarity with the disease types and surgical methods of schwannoma,the over-reliance on computer coding,the lack of code review and quality control in the coding system,and other reasons,schwannoma is often miscoded as benign tumor at the site of disease.This paper introduces the clinical features,diseases and surgical codes of schwannoma,and analyzes the reasons of coding errors through a retrospective study of 3 typical cases of schwannoma,and summarizes the coding ideas of schwannoma.Medical institutions should attach great importance to coding,constantly improve the professional ability and responsibility of the coders,and improve the accuracy of disease and surgical coding through the establishment of specialist coders and the establishment of the code review mechanism on the front page of medical records.

关 键 词：神经鞘瘤 ICD-10 ICD-9-CM-3 案例分析 

分 类 号：R197.323.1[医药卫生—卫生事业管理]