冠状动脉旁路移植术编码探讨  

Discussion on coding of coronary artery bypass grafting

作　　者：张宝珍[1] 陈玲[1] 许萍[1] 陈淡芬 ZHANG Baozhen;CHEN Ling;XU Ping;CHEN Danfen(The Fifth Affiliated Hospital of Sun Yat sen University,Zhuhai 519000,China)

机构地区：[1]中山大学附属第五医院,广东珠海519000

出　　处：《现代医院》2022年第9期1391-1393,共3页Modern Hospitals

摘　　要：目的 通过分析某院冠状动脉旁路移植术编码情况,探讨编码错误的原因,以提高编码准确性。方法 利用病案信息管理系统调取2019年8月—2022年3月以手术编码36.1冠状动脉旁路移植术为检索区间筛选出29份住院病案,核查每份病案手术及操作编码。结果 回顾性调查29份病案,手术及操作编码缺陷共17份,错误率达58.6%;错误类型中多编错误最多占62%;多编其他搭桥吻合术36.19及错编主动脉-冠状动脉搭桥术条目数(36.10~36.14)占主要错误,分别占54%及占31%。结论 导致错编主动脉-状动脉搭桥术条目数(36.10~36.14)的原因是将乳房内动脉-冠脉搭桥(36.15~36.16)、腹动脉/胃网膜动脉-冠状动脉搭桥36.17、其他动脉如锁骨下动脉/颈总动脉-冠状动脉搭桥36.19等均列入主动脉-冠状动脉搭桥(36.11~36.14)来计算搭桥的数量;多编其他搭桥吻合术36.19的原因是将主动脉-冠状动脉搭桥(36.11~36.14)已包含用自体取大隐静脉、桡动脉作为桥血管,仍多编36.19附加编码来说明。Objective By analyzing the coding of coronary artery bypass grafting in a hospital,the causes of coding errors were discussed to improve the accuracy of coding.Methods The medical record information management system was used to retrieve 29 inpatient medical records from August 2019 to March 2022.The operation code 36.1 coronary artery bypass grafting was used as the search interval to check the operation and operation code of each medical record.Results A retrospective survey of 29 cases showed that 17 cases had defects in operation and operation codes,and the error rate was 58.6%;Among the error types,the number of multiple errors accounts for 62% at most;The number of items(36.10-36.14) of other bypass anastomosis and wrong aortic coronary artery bypass grafting accounted for the main errors,accounting for 54% and 31% respectively.Conclusion The reason for the wrong number of aortic coronary artery bypass grafts(36.10-36.14) is that internal mammary artery coronary artery bypass grafts(36.15-36.16),abdominal artery/gastroepiploic artery coronary artery bypass grafts 36.17,and other arteries such as subclavian artery/common carotid artery coronary artery bypass grafts 36.19 are included in aortic coronary artery bypass grafts(36.11-36.14) to calculate the number of bypass grafts;And other bypass anastomosis 36.19.The reason is that aortic coronary artery bypass(36.11-36.14) has included autologous saphenous vein and radial artery as bridge vessels,and 36.19 additional code is still compiled to explain.

关 键 词：冠状动脉旁路移植术 ICD-9-CM-3编码 编码分析 

分 类 号：R197.323.1[医药卫生—卫生事业管理]