成人先天性心血管病和介入治疗分类编码探讨  

Discussion on classification and coding of adult congenital cardiovascular disease and interventional therapy

作　　者：张帆 郑静[2] Zhang Fan;Zheng Jing(Medical Record Statistics Room, Guangxi International Zhuang Medicine Hospital, Nanning 530200, China;Cardiology Department, The First Affiliated Hospital Of Guangxi Medical University, Nanning 530021, China)

机构地区：[1]广西国际壮医医院病案统计室,广西南宁530200 [2]广西医科大学第一附属医院心内科,广西南宁530021

出　　处：《中国医院统计》2021年第6期538-541,共4页Chinese Journal of Hospital Statistics

基　　金：广西壮族自治区卫生与计划生育委员会科研课题(Z20180906)。

摘　　要：目的探讨成人先天性心血管病和介入治疗操作分类编码。方法查阅心内科成人先天性心血管病和成人先天性心脏病介入治疗相关资料和文献,根据国际疾病与手术操作分类原则,对病历进行准确的ICD-10和ICD-9-CM-3编码。结果原发孔型房间隔缺损分类到Q21.2;继发孔型房间隔缺损分类到Q21.1;室间隔缺损分类到Q21.0;动脉导管未闭分类到Q25.0;肺动脉瓣狭窄分类到Q25.6;二叶主动脉瓣分类到Q23.1;三尖瓣下移畸形分类到Q22.5;先天性主动脉缩窄分类到Q23.0;主动脉窦动脉瘤分类到Q25.4;法洛四联症分类到Q21.3。经皮球囊肺动脉瓣成形术(PBPV)和经皮球囊主动脉瓣成形术(PBAV)分类到35.96;动脉导管未闭封堵术分类到38.85;房间隔缺损封堵术分类到35.52;室间隔缺损封堵术分类到35.55。结论编码员应经过专业的学习和考核,掌握ICD分类原则和编码技能,学习和积累临床医学知识并了解医学新进展,日常工作中积极主动与临床医师沟通;建立编码质控机制,不断提高编码质量。Objective To investigate the classification codes of adult congenital cardiovascular disease and interventional therapy.Methods By studying the information and literature on interventional treatment of adult congenital cardiovascular disease and adult congenital heart disease in cardiology,according to the classification principle of international disease and surgical operation,we carefully read the medical records for accurate coding of ICD-10 and ICD-9-CM-3.Results Primary atrial septal defect was classified to Q21.2;secondary atrial septal defect was classified to Q21.1;ventricular septal defect was classified to Q21.0;patent ductus arteriosus was classified to Q25.0;pulmonary stenosis was classified to Q25.6;bicuspid aortic valve was classified to Q23.1;tricuspid valvular malformation was classified to Q22.5;congenital aortic coarctation was classified to Q23.0;aortic sinus aneurysm was classified to Q25.4;the tetralogy of fallot was classified to Q21.3.Percutaneous balloon pulmonary valvuloplasty(PBPV)and percutaneous balloon aortic valvuloplasty(PBAV)were classified to 35.96;patent ductus arteriosus closure was classified to 38.85;atrial septal defect closure was classified to 35.52;the interval defect closure was classified to 35.55.Conclusion The coders must undergo professional study and assessment,master ICD classification principles and coding skills,learn and accumulate clinical medical knowledge and understand new medical advances,actively communicate with clinicians in daily work,establish coding quality control mechanisms,and continuously improve coding quality.

关 键 词：先天性心血管病 介入治疗 ICD-10 ICD-9-CM-3 

分 类 号：R119.732.31[医药卫生—公共卫生与预防医学]