直肠癌根治术手术编码的探讨  

Discussion on the Surgical Code of Rectal Cancer Radical Resection

作　　者：邬小凤 侯煜杰 黄娜萍 方丹丹 刘红[1] 康亮[1] 赵云龙 Wu Xiaofeng;Hou Yujie;Huang Naping;Fang Dandan;Liu Hong;Kang Liang;Zhao Yunlong(The sixth Affiliated Hospital of Sun Yat-sen University,Guangzhou 510000,Guangdong Province,China;不详)

机构地区：[1]中山大学附属第六医院,广东省广州市510000

出　　处：《中国病案》2020年第11期43-46,共4页Chinese Medical Record

摘　　要：为了提高直肠癌根治术的编码准确性,结合国际疾病分类第九版临床修订本手术与操作(ICD-9-CM-3)2011版中直肠切除术48.4-48.6的分类标准,某三级甲等综合性医院临床常用的7种直肠癌根治术的术式,Bacon术、Parks术、taTME术、NOSES术属于拖出术,主要手术的类目码是48.4;Miles术是经腹会阴的手术,主要手术的类目码是48.5;Hartmann术、Dixon术归类于残余类目,主要手术的类目码是48.6。这7种手术常规的附加手术编码有肠系膜切除术(54.4)、淋巴结清扫(40.59)、引流(54.19),而是否肠造口一般是根据患者是否可能发生吻合口瘘的情况而定。To improve the coding accuracy of radical surgery for rectal cancer,according to the 7 surgical methods of radical surgery for rectal cancer commonly used in a Three A and Tertiary Hospital and combing with the classification criteria of the proctectomy(the categories are 48.4-48.6)in international classification of diseases clinical modification of 9 th revision operations and procedures 2011 th edition(ICD-9-CM-3),the researchers explored the Bacon operation,the Parks operation,the taTME operation,the NOSES operation are Pull-through operations,their three-character category code is 48.4.The Miles operation was abdominoperineal,its code is 48.5.The Hartmann operation and the Dixon operation belong other category,their code are 48.6.The affiliated surgical codes of these 7 operations include the mesenterectomy(its code is 54.4),the radical excision of lymph nodes(its code is 40.59)and the ventral drainage(its code is 54.19).If Patients may have anastomotic fistula,the enterostomy will happen.

关 键 词：手术编码 直肠癌根治术 术式 ICD-9-CM-31 

分 类 号：R197.323[医药卫生—卫生事业管理]