支气管袖状肺叶切除术ICD-9-CM-3编码的探讨  

Investigation on ICD-9-CM-3 Coding of Bronchial Sleeve Lobectomy of Lung Cancer

作　　者：李躲 汪刚[1] 荣雯雯 Li Duo;Wang Gang;Rong Wenwen(The Center Statistics,Shanghai Chest Hospital Affiliated Shanghai Jiaotong University,Shanghai 200030,China;不详)

机构地区：[1]上海市胸科医院上海交通大学附属胸科医院统计中心,上海市200030

出　　处：《中国病案》2022年第6期53-55,共3页Chinese Medical Record

摘　　要：目的 回顾性分析支气管袖状肺叶切除术正确的ICD-9-CM-3编码,以提高手术编码的准确性。方法 从病案系统检索某院2019年1月1日至2019年12月31日支气管袖状肺叶切除术病案共90份,用Excel表总结编码存在问题,并分析原因。结果 90份支气管袖状肺叶切除术病案中,共88份存在编码错误,其中84份单袖切除术编码错误,错误率为97.67%,2份双袖切除术编码错误,错误率为100%。88份编码错误病案均存在一个或多个问题,如错编肺叶切除术(47例),漏编肺叶切除术(16例)、支气管袖状切除术(74例)、支气管成形术(43例)及肺动脉切除术伴成形术(1例);分析其原因主要有:编码员对术式认识不足(75例);编码库中拓展码欠精准(47例);编码员不熟悉编码规则(43例);医师书写不规范(16例)。结论 支气管袖状肺叶切除术手术术式复杂,ICD-9-CM-3中没有特定编码涵盖这一术式,为了提高编码的准确性,编码员应保持与临床医师沟通,加强责任心,积极学习临床和编码知识,根据手术步骤,使用ICD-9-CM-3工具书,按主导词查找编码。Objectives To retrospectively analyze the correct ICD-9-CM-3 coding in bronchial sleeve lobectomy in order to improve the accuracy of surgical coding.Methods A total of 90 medical records of bronchial sleeve lobectomy in a hospital from January 1 st,2019 to December 31 st,2019 were retrieved from the medical record system.The coding problems were summarized and analyzed by Excel.Results Among the 90 cases of bronchial sleeve lobectomy,88 cases had coding errors,of which 84 cases of single sleeve lobectomy had coding errors,the error rate was 97.67%,and 2 cases of double sleeve lobectomy had coding errors,the error rate was 100%.88 medical records with wrong coding had one or more problems,such as wrong coding of lobectomy(47 cases),missing coding of lobectomy(16 cases),bronchial sleeve resection(74 cases),bronchoplasty(43 cases) and pulmonary artery resection with plasty(1 case);The main reasons were as follows:the coder had insufficient understanding of the operation(75 cases);The expansion code in the coding library was not accurate(47 cases);Coders were not familiar with coding rules(43 cases);Doctors’ writing was not standardized(16 cases).Conclusions The surgical procedure of bronchial sleeve lobectomy was complex,and there was no specific code in ICD-9-CM-3 to cover this procedure.In order to improve the accuracy of coding,the coder should maintain communication with clinicians,strengthen the sense of responsibility,actively learn clinical and coding knowledge,and use ICD-9-CM-3 reference book to find the code according to the leading words according to the surgical steps.

关 键 词：支气管袖状肺叶切除术 ICD-9-CM-3 

分 类 号：R734.2[医药卫生—肿瘤] R197.323[医药卫生—临床医学]