皮肤瘢痕疾病及手术编码探讨  

Discussion on the Code of Skin Scar Disease and Operation

作　　者：郑金龙 Zheng Jinlong(Plastic Surgery Hospital of Chinese Academy of Medical Sciences,Beijing 100144,China)

机构地区：[1]中国医学科学院整形外科医院,北京市100144

出　　处：《中国病案》2022年第5期14-16,共3页Chinese Medical Record

摘　　要：皮肤瘢痕及相关手术是常见的疾病和手术之一,编码容易混淆。临床上根据临床表现和组织学改变将皮肤瘢痕分为表浅性瘢痕、增生性瘢痕、萎缩性瘢痕、瘢痕疙瘩、蹼状瘢痕、凹陷性瘢痕、桥状瘢痕,ICD-10将皮肤瘢痕分类于皮肤萎缩性疾患,瘢痕疙瘩分类于皮肤肥厚性疾患,眼睑、耳廓、外阴、阴茎、阴唇、膀胱、肛门、中耳等部位的皮肤瘢痕分类于系统章节。对瘢痕手术进行编码时,临床上单纯瘢痕切除术编码为86.3,耳廓、鼻、乳房、阴囊、眼睑、包皮、会阴等皮肤瘢痕切除术分类于系统章节。皮肤磨削术编码为86.25,皮肤瘢痕松解术86.84,皮肤瘢痕切除游离植皮术、皮肤瘢痕切除皮瓣移植术编码时除了将对瘢痕切除术进行编码,还要对游离皮片移植术和皮瓣移植术进行编码。编码员对皮肤瘢痕及其常见手术编码时要了解瘢痕临床表现和部位及其手术术式和部位,根据ICD-10及ICD-9-CM-3编码规则准确编码。Skin scar and related operation is one of the common diseases and operations,the code is easy to confuse.Clinically,skin scars are divided into superficial scar,hypertrophic scar,atrophic scar,keloid,webbed scar,depression scar and bridge scar according to clinical manifestations and histological changes.Icd-10 classifies skin scars into atrophic skin diseases and keloid into hypertrophic skin diseases.Skin scars of eyelid,ear,vulva,penis,labia,bladder,anus and middle ear are classified in the systematic section.When coding scar surgery,the clinical code of simple scar resection is 86.3,and skin scar resection such as auricle,nose,breast,scrotum,eyelid,prepuce and perineum is classified in the systematic section.The coding of skin grinding is 86.25,skin scar release is 86.84,and the coding of free skin grafting for skin scar excision and skin flap transplantation for skin scar excision is not only coding for scar excision,but also coding for free skin graft and skin flap transplantation.When coding skin scar and its common operations,coders should understand the clinical manifestations and locations of scar and the surgical methods and locations,and code accurately according to ICD-10 and ICD-9-CM-3coding rules.

关 键 词：皮肤瘢痕 瘢痕切除术 ICD-10 ICD-9-CM-3 编码 

分 类 号：R197.323[医药卫生—卫生事业管理] R622[医药卫生—公共卫生与预防医学]