腰椎间盘手术编码错误分析  

Analysis of Coding Errors in Lumbar Intervertebral Disc Surgery

作　　者：刘天野 任月荣 郑博闻 刘辰龙[1] Liu Tianye;Ren Yuerong;Zheng Bowen;LiuChenlong(Peking University First Hospital,Beijing 100034,China)

机构地区：[1]北京大学第一医院,北京市100034

出　　处：《中国病案》2021年第4期44-46,共3页Chinese Medical Record

摘　　要：腰椎间盘手术编码在ICD-9-CM-3中分类在80.5当中,编码较为复杂,编码过程中常出现错误。手术的省略编码可能会导致多编码问题,附加编码可能会导致漏编等问题。本文使用某院住院病案首页信息查询系统,对2020年1月1日-2020年6月30日腰椎间盘手术编码为80.5的出院病案进行检索,并重新核查。对椎间盘切除术80.51、椎间盘纤维环修补术80.54、椎间盘射频消融术80.59的三个案例进行分析,总结腰椎间盘手术的编码错误类型分别为多编、错编和漏编。分析编码员编码错误的原因,并提出对应的编码要点和改进措施,从而提高编码员对腰椎间盘手术编码的准确性。The code of lumbar intervertebral disc surgery is classified in 80.5 in ICD-9-CM-3,surgical coding is more complicated,errors often occur during encoding. Omission of codes for surgery may cause multiple coding problems,additional codes may cause problems such as missing codes. This article uses a hospital medical record home page information query system, retrieval of hospital discharge records with a lumbar disc surgery code 80.5 from January 1 to June 30, 2020, and recheck. Three cases of diskectomy 80.51, anular dis repair 80.54, and radiofrequency ablation 80.59 were analyzed, summarize the coding error types of lumbar intervertebral disc surgery are multiple coding, wrong coding and missing coding.Analyze the causes of coding errors by coders, and put forward the corresponding coding points and improvement measures.

关 键 词：ICD-9-CM-3 错误分析 腰椎间盘 编码分析 

分 类 号：R687.3[医药卫生—骨科学]