恶性黑色素瘤ICD编码案例分析  

Case Analysis of ICD Coding for Malignant Melanoma

作　　者：隗和澎 隗和红 季新强[1] 刘晶[1] Wei Hepeng;Wei He Hong;Ji Xinqiang;Liu Jing(Key laboratory of Carcinogenesis and Translational Research(Ministry of Education/Beijing),Peking University Cancer Hospital&Institute,Beijing 100142,China;不详)

机构地区：[1]北京大学肿瘤医院暨北京市肿瘤防治研究所病案统计室,恶性肿瘤发病机制及转化研究教育部重点实验室,北京市100142 [2]北京市第六医院病案室,北京市100007

出　　处：《中国病案》2020年第11期38-40,共3页Chinese Medical Record

摘　　要：恶性黑色素瘤是由皮肤和其他器官黑素细胞产生的肿瘤,可发生在人体各个部位。ICD-10对于恶性黑色素瘤部位分类特殊,形态学编码分类多样,易造成编码错误。ICD-10将恶性黑色素瘤的部位编码与形态学编码进行了先组配,不应按照肿瘤编码查找原则进行查找。ICD-10恶性黑色素瘤索引下列出了共计80个黑色素瘤部位编码,按部位分类可归纳为皮肤恶性黑色素瘤(不包含生殖器官)(C43)、生殖器官皮肤恶性黑色素瘤(C51-C52、C60、C63)、眼部恶性黑色素瘤(C69)、体内部位的恶性黑色素瘤(编码于该部位的恶性肿瘤)和未特指部位恶性黑色素瘤(C43.9)。临床最常见的5种病理分型及对应形态学编码分别为未特指分型恶性黑(色素)瘤(M8720/3)、浅表扩散型黑色素瘤(M8743/3)、结节型黑色素瘤(M8721/3)、恶性雀斑样黑色素瘤(M8742/3)和肢端雀斑样黑色素瘤(M8744/3)。编码人员应该通过定期加强ICD各章节知识系统学习,多与临床医师沟通提高临床知识储备,完善编码质控环节等方法提高编码准确率。Malignant melanoma can occur in all parts of the human body,its production is caused by melanocytes in the skin and other organs.In view of the special classification of malignant melanoma site by ICD-10 and the diversity of morphological coding classification,it is easy to cause coding errors.Since ICD-10 combines the location code and morphological code of malignant melanoma,it should not be searched according to the principle of tumor code search.A total of 80 melanoma site codes are listed under the ICD-0 Malignant Melanoma Index.If they are classified by site,they can be classified as cutaneous malignant melanoma(including reproductive organs)(C43),malignant melanoma of genital skin(C51-C52,C6,C63),ocular malignant melanoma(C69),malignant melanoma in the body(malignant tumor coded at that site),and undiagnosed malignant melanoma(C43.9).The five most common pathological types and their corresponding morphological codes shown in the clinic are as follows,which are unspecified type malignant melanoma(M8720/3)and superficial spreading melanoma(M8743/3),Nodular melanoma(M8721/3),malignant freckle-like melanoma(M842/3)and acral freckle-like melanoma(M8744/3).For coders,they should strengthen the systematic learning of ICD chapters regularly,communicate with clinicians more,improve the quality control of coding and other methods to improve the coding accuracy.

关 键 词：恶性黑色素瘤 ICD-10 案例 

分 类 号：R739.5[医药卫生—肿瘤]