皮肤外科局部皮瓣移植术的编码探讨  

Discussion on the Coding of Local Skin Flap Transplantation in Dermatologic Surgery

作　　者：刘伦[1] 黄爱丽[1] 曾云 寇沛[1] Liu Lun;Huang Aili;Zeng Yun;Kou Pei(Medical Record Statistics Office,Wuhan First Hospital,Wuhan 430022,Hubei Province,China;不详)

机构地区：[1]武汉市第一医院病案统计室,湖北省武汉市430022

出　　处：《中国病案》2020年第8期43-45,共3页Chinese Medical Record

摘　　要：因皮瓣移植术专业性强,临床分类与ICD分类差异较大,编码工作中该术式错编、漏编情况较多。为提高皮肤外科皮瓣移植术的编码准确率,将临床分类方式与ICD中的分类规则进行对比和分析,并进行案例解析,从而理清常见皮瓣移植术的ICD编码。编码员在编码皮瓣移植术时,一是要区分皮瓣种类,是带蒂皮瓣还是其他皮瓣,二是要明确手术方式,是前徙术还是其他术式,三是要区分手术部位,是手部、其他特殊部位还是一般部位。编码员需与临床医师沟通的同时也需加强临床知识和编码规则的学习,在实践中不断提升编码质量。Because of the specialty of skin flap transplantation, the difference between clinical classification and ICD classification is large, and there are many mistakes and omissions in coding.In order to improve the coding accuracy of skin flap transplantation, the clinical classification method is compared and analyzed with the classification rules in ICD, and case analysis is carried out to clarify the ICD coding of common skin flap transplantation. When coders coding flap transplantation, the first is to pay attention to distinguish between types of skin flap, pedicle skin flap or other skin flap, the second is to clear the operation way, isadvance flap graft or other operation, the third is to distinguish between the surgical site, hands, and other special parts or parts in general.Coders should not only communicate with clinicians, but also enhance the learning of clinical knowledge and coding principles, so as to continuously improve coding quality in practice.

关 键 词：皮肤外科 局部皮瓣移植术 ICD-9-CM-3 编码 

分 类 号：R622.1[医药卫生—整形外科]