某院乳房良性肿瘤ICD-10编码质量分析  

Analysis of ICD-10 Coding Quality for Benign Neoplasm of Breast

作　　者：占云 彭君[1] 潘振宇[1] Zhan Yun;Pen Jun;Pan Zhenyu(Zhongnan Hospital of Wuhan University,Wuhan 430071,Hubei Province,China)

机构地区：[1]武汉大学中南医院,湖北省武汉市430071

出　　处：《中国病案》2020年第7期37-39,共3页Chinese Medical Record

摘　　要：目的提高乳房良性肿瘤ICD-10编码准确率。方法从某院病案管理系统检索2018年1月1日-2018年12月31日期间住院病案首页中主要诊断编码为D24的病案721份,按照《疾病和有关健康问题的国际统计分类ICD-10》中肿瘤的编码规则,结合病理报告,核对乳房良性肿瘤编码并进行汇总分析。结果721份病案中,错误编码病案39份,编码准确率为94.59%。在错误编码病案中,48.72%是仅病理诊断编码错误,33.33%是主要编码和病理诊断编码均错误,17.95%是仅主要编码错误。仅病理诊断编码错误病案中,84.21%是良性叶状肿瘤、10.53%是纤维瘤、5.26%是管状腺瘤。主要编码和病理诊断编码均错误病案中,38.46%是乳房错构瘤、23.08%是表皮样囊肿、15.38%是积乳囊肿、软纤维瘤及毛母细胞瘤和钙化上皮瘤各占7.69%。仅主要编码错误病案中,85.71%是脂肪瘤,14.29%是毛囊瘤。结论乳房良性肿瘤ICD-10分类编码错误率较低,主要表现在病理诊断编码错误,其次是疾病编码错误。因此,编码员在肿瘤编码实践中,务必要严格遵循肿瘤的编码方法,不可依赖电子编码库或仅对临床医师书写的疾病诊断进行编码,其次要加强相关医学知识学习。Objective To improve the accuracy of the ICD-10 coding quality for benign neoplasm of breast.Methods To retrieve 721 medical records of primary diagnosis coding with D24 in the front pages of medical records from 1 st January 2018 to 1 st December 2018 with the application of hospital medical record management system.To take the ICD-10,check the coding for benign neoplasm of breast according to the pathological reports and make summarize analysis.Results Among 721 cases of benign neoplasm of breast,39 cases were miscoded,with a total accuracy rate of 94.59%.Among the 39 cases which were miscoded,48.72%could ascribe to only the pathological diagnosis coding error,33.33%to the disease coding error as well as the morphological coding error,and 17.95%to the disease coding error.19 cases of only the pathological diagnosis coding error,include phyllode tumor,fibroma and tubular adenoma,accounting for 84.21%,10.53%and 5.26%respectively.13 cases of the disease as well as the morphological coding error,include hamartoma,epidermoid cyst,galactocele,soft fibroma,trichoblastoma and calcifying epithelioma,accounting for 38.46%,23.08%,15.38%,7.69%,7.69%,and 7.69%respectively.7 cases of only the disease coding error,include lipoma and trichofolliculoma,accounting for 85.71%and 14.29%respectively.Conclusions The error of the ICD-10 coding for benign neoplasm of breast was low.Much of them can ascribe to the pathological diagnosis coding error,and the next to the disease coding error.In the process of coding neoplasms,coder,therefor,must follow the coding rules,shouldn’t depend on electronic coding libraries or code just according to the disease diagnosis,moreover,learn more about related knowledge of medicine.

关 键 词：乳房 良性肿瘤 编码 ICD-10 住院病案首页 病理诊断报告 

分 类 号：R197.323[医药卫生—卫生事业管理]