常见的胰腺癌根治术案例分析及编码探讨  

Cases Analysis and Coding Method Discussion of Cerebral Infarction

作　　者：邱雨涛 何玉芸 赖丽文[1] 赵淑媛[1] Qiu Yutao;He Yuyun;Lai Liwen;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3期52-55,共4页Chinese Medical Record

摘　　要：胰腺癌根治术是目前胰腺恶性肿瘤常见的手术治疗方法。随着医学的发展,手术方法不断更新,胰腺癌术式ICD-9-CM-3编码较为复杂,临床医师与编码员在填写病案首页时易混淆手术名称和编码。临床上常用的胰腺癌根治术以及其对应编码:(1)Whipple术,52.7;(2)保留幽门的胰十二指肠切除术(PPPD),52.7;(3)胰体尾癌根治术,52.53;(4)Child术,52.53;(5)根治术性胰腺切除术,52.7。结合案例介绍这5种胰腺癌根治术各种术式,进行对应编码分析,有助于编码员熟悉各种胰腺癌根治术术式,丰富ICD编码专业知识及临床知识,通过与临床医师的沟通,增强自身责任感,定期组织参加培训,发现科室内部相关问题并及时调整,以提高胰腺恶性肿瘤编码准确率。The radical resection of pancreatic cancer is the common surgical treatment for malignant tumor at present,and it constantly renews itself along with the development of medical science.Due to the complexity of ICD-9-CM-3,it is apt for clinicians and coders to confuse the nomenclatures or codes when they are filling in the front cover of medical records of this specific surgical procedure.At present,the commonly used radical resection of pancreatic cancer and its corresponding codes include:(1)Whipple procedure,52.7;(2)Pylorus preserving pancreatoduodenectomy,52.7;(3)Radical resection of left-sided pancreatic cancer,52.53;(4)Child procedure,52.53;(5)Radical resection of the pancreas,52.7.This paper introduces various radical resection of pancreatic cancer by analyzing cases and corresponding codes,aiming to acquaint the ICD coders with various nomenclatures and codes,systematize the professional and clinic knowledge of ICD codes,enhance the communication between ICD coders and clinicians,adjust the internal mechanism between departments,as well as improve the accuracy of coding.

关 键 词：胰腺癌根治术 手术编码 ICD-9-CM-3 

分 类 号：R735.9[医药卫生—肿瘤] R197.323[医药卫生—临床医学]