浅析3例疑难肿瘤ICD-10编码  

Analysis on the ICD-10 Coding of Three Cases of Complicated Tumors

作　　者：陶培东 唐晓慧 贾元元[1] Tao Peidong;Tang Xiaohui;Jia Yuanyuan(Chongqing Traditional Chinese Medicine Hospital,Chongqing 400020,China;不详)

机构地区：[1]重庆市中医院病案统计科,重庆市400020 [2]重庆市中医院肿瘤科,重庆市400020

出　　处：《中国病案》2020年第3期31-33,共3页Chinese Medical Record

摘　　要：目的探讨复杂肿瘤诊断的编码方法,提高疑难肿瘤疾病编码的准确性。方法综合分析病例,查阅肿瘤相关文献书籍,与临床病理医师沟通,研究分析背部毛鞘棘皮瘤、阑尾神经内分泌瘤G1期、纵膈节细胞神经瘤3例疑难肿瘤编码。结果3例疑难肿瘤无法直接查到编码,查阅WHO肿瘤病理组织学分类等相关文献书籍,确定背部毛鞘棘皮瘤编码为D23.5M8104/0、阑尾神经内分泌瘤G1期编码为D37.3M8240/1、纵膈节细胞神经瘤编码为D15.2 M9492/0。结论肿瘤诊断信息丰富,编码员需具备高度责任心,仔细阅读病案,积极与临床病理医师沟通,关注WHO肿瘤组织学分类进展,才能不断提高疑难肿瘤编码的准确性,保障DRGs顺利实施。Objectives To explore the coding method of complex tumor diagnosis and improve the accuracy of coding of difficult tumor diseases.Methods Through comprehensive analysis of cases,consult the oncological literature books,communication with clinicians to study and analyze the coding of 3 cases of complicated tumors,including the back’s Pilar sheath acanthoma,appendix neuroendocrine tumor G1 phase and mediastinal ganglioneuroma.Results The coding of 3 cases of complicated tumors could not be found directly.According to the WHO tumor histophiological classification and other relevant literatures,the code for the back’s Pilar sheath acanthoma was D23.5 M8104/0;the code for appendix neuroendocrine tumor G1 phase was D37.3 M8240/1;the code for mediastinal ganglioneuroma was D15.2 M9492/0.Conclusions Faced with The abundant tumor diagnosis information,it was necessary for the coders to have a high sense of responsibility,we should read the medical records carefully,consult with the clinician actively,pay attention to the progress of WHO tumor histology classification,so as to improve the accuracy of the difficult tumor coding continuously and ensure the smooth implementation of DRG.

关 键 词：ICD-10 毛鞘棘皮瘤 神经内分泌瘤 节细胞神经瘤 

分 类 号：R197.323[医药卫生—卫生事业管理]