乳腺增生症ICD-10编码案例分析  

Study on ICD-10 Code of Mammary Hyperplasia

作　　者：段沁江 钱虹[2] Duan Qinjiang;Qian Hong(Jiangsu Health Vocational College,Nanjing 211800,Jiangsu Province,China;不详)

机构地区：[1]江苏卫生健康职业学院,江苏省南京市211800 [2]兰州大学第一医院,甘肃省兰州市730000

出　　处：《中国病案》2021年第7期38-40,共3页Chinese Medical Record

摘　　要：乳腺增生症命名繁多,病理形态多样,可分为囊性增生和腺性增生。囊性增生以乳腺导管扩张和导管上皮增生为主要改变。腺性增生以乳腺小叶和结缔组织增生为主要特征。ICD-10以组织病理学对其分类,乳腺囊肿编码N60.0,其他囊性增生症编码N60.1,硬化性乳腺腺病编码N60.3,其他腺性增生编码N60.2。乳腺囊肿和硬化性腺病分别是囊性增生和腺性增生的晚期形态。乳腺增生症各型病理变化可单独存在,也可同时出现。编码时应查看具体病理类型,针对主要病理类型进行编码。不同病理类型构成大致相当时,编码乳腺增生症晚期形态。诊断名称仅是编码的重要参考,应与临床科室和病理科多沟通,以病理为依据,按照ICD-10规则正确编码。Hyperplasia of mammary glands has many names and pathological forms,which can be divided into cystic hyperplasia and glandular hyperplasia.The main changes of cystic hyperplasia were mammary duct dilatation and ductal epithelial hyperplasia.Glandular hyperplasia is characterized by lobular and connective tissue hyperplasia.ICD-10 was classified by histopathology:breast cyst n60.0,other cystic hyperplasia n60.1,sclerosing adenosis n60.3,other adenosis n60.2.Breast cyst and sclerosing adenosis are the late forms of cystic hyperplasia and glandular hyperplasia respectively.The pathological changes of each type of hyperplasia of mammary glands may exist alone or at the same time.When coding,we should check the specific pathological types and code the main pathological types.When the constitution of different pathological types is roughly the same,it encodes the late morphology of hyperplasia of mammary glands.The diagnosis name is only an important reference for coding.It should be communicated with clinical and pathological departments,and be correctly coded according to ICD-10 rules based on pathology.

关 键 词：乳腺增生症 ICD-10 编码 

分 类 号：R197.323[医药卫生—卫生事业管理]