甲状腺肿瘤的常见手术方式及ICD-9-CM-3编码解析  

Analysis on the Common Operation and ICD-9-CM-3 Coding of Thyroid Gland Surgery

作　　者：孙佳希 陈婷[1] Sun Jiaxi;Chen Ting(Beijing Tongren Hospital affiliated to Capital Medical University,Beijing 100730,China)

机构地区：[1]首都医科大学附属北京同仁医院,北京市100730

出　　处：《中国病案》2021年第10期47-49,共3页Chinese Medical Record

摘　　要：甲状腺肿瘤由于甲状腺的解剖结构和疾病性质不同,手术的难易程度和切除范围也会不同。甲状腺切除术的分类轴心是入路+范围。按入路分:颈部入路的亚目为06.2-06.4,若为胸骨下入路的亚目则归类为06.5以及舌部入路的亚目归类为06.6。在颈部入路按照切除的范围分为单侧甲状腺叶切除06.2、部分切除06.3和全部甲状腺切除06.4。分析甲状腺不同手术的编码方法、手术需要切除的范围以及在ICD-9-CM-3工具书中如何进行查找,明确和规范甲状腺手术ICD-9-CM-3手术及操作分类的正确编码。编码员应充分了解甲状腺的解剖结构和各种手术术式,通过阅读住院病案中的手术记录,了解手术内涵,不断提高从手术记录中提取编码关键信息的能力,提高甲状腺手术的编码质量。Due to the different anatomical structure and disease nature of thyroid tumor,the degree of difficulty and scope of resection of thyroid tumor are also different.The classified axis of thyroidectomy is the approach+range.According to the approach,the suborders of the neck,substernum and tongue were 06.2-06.4,06.5 and 06.6,respectively.According to the scope of resection,the cervical approach can be divided into unilateral lobectomy 06.2,partial thyroidectomy 06.3 and total thyroidectomy 06.4.According to different cases,the coding ideas of different thyroid surgeries were analyzed,the surgical resection scope was summarized and how to find it in the ICD-9-CM-3 reference book,so as to clarify and standardize the correct coding of ICD-9-CM-3 surgery and medical operation classification for thyroid surgery.Coders should fully understand the various thyroid surgery methods,and constantly improve the ability to extract coding key information from the surgical records by reading the surgical records in the hospital records,so as to improve the coding quality of thyroid surgery.

关 键 词：甲状腺 手术 ICD-9-CM-3 

分 类 号：R736.1[医药卫生—肿瘤] R197.323[医药卫生—临床医学]