特指组织肿瘤的ICD-10编码分析  

Analysis of ICD-10 Coding Errors of Special Tissue Tumor

作　　者：韩丽 徐静[1] 边鹏 周海滨[1] Han Li;Xu Jing;Bian Peng;Zhou Haibin(Liaocheng people’s Hospital,Liaocheng 252000,Shangdong Province,China;不详)

机构地区：[1]山东省聊城市人民医院,山东省聊城市252000 [2]山东省立医院,山东省济南市250000

出　　处：《中国病案》2021年第8期56-58,共3页Chinese Medical Record

摘　　要：目的通过对皮肤、神经、结缔组织等特指组织的部分编码质控,分析常见的编码错误,以提高肿瘤形态学编码和肿瘤部位编码的准确性。方法在某三级甲等医院的病案缺陷反馈系统中,检索2018年1月1日至2020年10月1日出院病案中包含皮肤、神经、结缔组织病理诊断的712份病案,由资深编码员2名和病理科主治医师2名组成质控小组,对存在的问题进行汇总分析。结果皮肤恶性肿瘤以C43、C44为主要诊断错编率是8.33%,以基底细胞癌为病理错编率是30.19%;神经系统肿瘤以D36.1为主要诊断错编率13.95%,以神经鞘瘤为病理错编率是17.13%;结缔组织肿瘤以D21为主要诊断错编率是31.11%,以C49为主要诊断错编率是16.30%,以D48.1为主要诊断错编率40.00%。结论皮肤、神经、结缔组织等特指组织的编码中主要诊断错编率在8%-40%,应引起重视,提高特指组织恶性肿瘤编码的正确性。Objective According to the quality control of some coding of special tissue(skin,nerve,connective tissue),we analyze the common coding errors to improve the accuracy of pathological diagnosis coding and tumor site coding.Methods A total of 712 medical records with pathological diagnosis of specific tissues(skin,nerve,connective tissue)from January 1,2018 to October 1,2020 were totally selected from the defect feedback system for medical records in the top three hospital,and the existing problems were statistically analyzed by the quality control group.The group was composed of 2 senior coders and 2 attending pathologists.Results Base on the condition of C43/C44 as the main code,the coding error rate was 8.33%,and base on the condition of“basal cell carcinoma”as the pathological diagnosis,the coding error rate was 30.19%.The coding error rate for peripheral nerves and autonomic nervous system(D36.1)is 13.95%,for neurilemmoma is 17.13%.The coding error rate for benign neoplasms of connective and other soft tissue(D21)is 31.11%,and 16.30%for malignant neoplasm of other connective and soft tissue(C49),and 40.00%for connective and other soft tissue(D48.1).Conclusion In order to improve the coding accuracy of the specific tissue tumor,the coders should check the ICD-10 reference books as much as possible and accumulate the pathological knowledge.Besides,they should establish good communication with doctors and pathologists and update relevant knowledge structure.

关 键 词：特指组织肿瘤 形态学编码 ICD-10 

分 类 号：R197.323[医药卫生—卫生事业管理] R73[医药卫生—公共卫生与预防医学]