胸腔镜下肺癌的根治性手术编码探讨  

Discussion on Coding of Radical Surgery for Lung Cancer under Thoracoscopy

作　　者：池旎 Chi Ni(Department of Medical Records,The Union Hospital Affiliated Hospital of Fujian Medical University,Fuzhou 350001,Fujian Province,China)

机构地区：[1]福建医科大学附属协和医院病案室,福建省福州市350001

出　　处：《中国病案》2021年第4期39-41,共3页Chinese Medical Record

摘　　要：胸腔镜下肺癌的根治性手术已成为治疗肺癌的新型手术方式,通过回顾5例肺癌患者的病案,针对胸腔镜下肺癌的根治性手术的不同术式和手术步骤介绍按照ICD-9-CM-3原则进行编码,旨在提高手术编码的准确性和统一性。胸腔镜下肺癌的根治性手术根据病变的切除范围,有5种常见术式及编码:胸腔镜下肺楔形切除术32.20;胸腔镜下肺段切除术32.30;胸腔镜下肺叶切除术32.41;胸镜下袖式肺叶切除术32.41+32.1+38.35;胸腔镜下全肺切除术32.50。编码工作要正确理解手术原理、目的,读懂手术记录,在此基础上结合ICD-9-CM-3的编码规则,根据不同术式给予相应的编码。要求编码人员要有较高的专业素质,了解相关临床知识,仔细阅读病案,加强与临床医师的沟通,同时规范临床医师的书写习惯,建立有效的质控体系,以提高病案编码质量。In recent years, Radical surgery for lung cancer under thoracoscopy has become a new surgical procedure for lung cancer, By reviewing five cases of lung cancer, different surgical procedures and procedures for radical thoracoscopic lung cancer: how to code according to ICD-9-CM-3 principles, The aim is to improve the accuracy and unity of surgical coding. Radical surgery for lung cancer under thoracoscopy, Here are the following common procedures and coding: thoracoscopic wedge resection 32.20;Thoracoscopic pneumonectomy 32.30;Thoracoscopic lobectomy 32.41;Thoracic sleeve lobectomy 32.41+32.1+38.35;Thoracoscopic total pneumonectomy 32.50. To understand the principle and purpose of the operation correctly, read the records, based on the ICD-9-CM-3 coding rules, according to different procedures to give the corresponding coding. Requires the coding personnel to have the higher professional quality, knowledge of clinical knowledge, read the medical records carefully, strengthen communication with clinicians, And regulate clinicians’ writing habits, establish an effective quality control system, in order to improve the quality of medical record coding.

关 键 词：胸腔镜下肺癌的根治性手术 术式 手术编码 

分 类 号：R734.2[医药卫生—肿瘤]