眼睑缝合术与重建术的编码探讨  

Discussion on the Coding Method of Eyelid Suture and Reconstruction

作　　者：邱雨涛 赖丽文[1] 何玉芸 赵淑媛[1] Qiu Yutao;Lai Liwen;He Yuyun;Zhao Shuyuan(Department of Medical Records,Guangdong People's Hospital,Guangdong Academy of Medical Sciences,Guangzhou 510080,Guangdong Province,China;不详)

机构地区：[1]广东省医学科学院广东省人民医院病案科,广东省广州市510080

出　　处：《中国病案》2021年第5期34-37,共4页Chinese Medical Record

摘　　要：眼睑缝合术与重建术在眼睑外科手术中出现的频率较高,同时在ICD-9-CM-3中的编码相对比较复杂,容易出现错误。睑缝合术分类轴心为疾病性质,不同疾病手术编码不同:上睑下垂的睑缝合术采用额肌睑板缝合法(08.31)为主要手术;睑内翻的睑缝合术编码08.42;单纯的睑位置调整的眼睑缝合术的编码为08.52;对于睑裂伤的缝合编码为08.81-08.85。睑重建术类目的分类轴心为是否有移植物的修补,包括用皮瓣或移植物眼睑重建术08.6与其他眼睑重建术08.7,各类目下亚目分类轴心为移植物的种类、缺损是否累及睑缘以及缺损的深度。编码员需要在充分了解手术的基础上,不断提高从手术记录中提取关键信息的能力,才能对睑缝合术与重建术进行正确的分类。Eyelid suture and reconstruction are frequently performed in eyelid surgery.Meanwhile,the coding in ICD-9-CM-3 is relatively complex and prone to errors,which requires extra attention.The classification axis of eyelid suture is the nature of the disease,and the operative codes of different diseases are different:frontal muscle suture(08.31)is the main operation in eyelid suture for ptosis;The number of eyelid suture for entropion was 08.42;The code of eyelid suture with simple eyelid position adjustment was 08.52.The suture code for eyelid laceration was 08.81-08.85.The classification axis of the categories of eyelid reconstruction was whether there was graft repair,including eyelid reconstruction with skin flap or graft 08.6 and other eyelid reconstruction 08.7.The classification axis of each suborder was the type of graft,whether the defect involved the eyelid margin and the depth of the defect.Coders need to improve their ability to extract critical information from surgical records based on a thorough understanding of the procedure so that they can correctly classify eyelid suture and reconstruction procedures.

关 键 词：睑缝合术 睑重建术 ICD-9-CM-3 手术编码 

分 类 号：R779.6[医药卫生—眼科] R197.323[医药卫生—临床医学]