黄斑前膜相关手术编码错误案例分析  

Coding errors in macular epiretinal membrane related surgeries:a case study

作　　者：韦献 吴学红 刘锦魁 曾勇 WEI Xian;WU Xuehong;LIU Jinkui;ZENG Yong(Liuzhou Red Cross Hospital,Guangxi Zhuang Autonomous Region,Liuzhou 545001,China)

机构地区：[1]柳州市红十字会医院,广西柳州545001

出　　处：《现代医院》2022年第11期1706-1709,共4页Modern Hospitals

基　　金：广西壮族自治区卫生健康委员会自筹经费科研课题(Z20200607)。

摘　　要：目的分析黄斑前膜相关手术编码中存在的问题及原因,提高编码的准确性。方法通过分析黄斑前膜的解剖、病理生理、病因分类及治疗方法,结合案例探讨黄斑前膜相关手术在国家临床版3.0手术操作编码(ICD-9-CM3)中的错误编码原因。结果黄斑前膜剥除术编码14.2900x002,视网膜下膜取出术需要手术切开视网膜编码于14.9x05,内界膜剥除需根据黄斑疾病的性质编码,黄斑水肿和黄斑前膜行内界膜剥除术编码于14.2900x004,黄斑裂孔行内界膜剥除术编码于14.3901,使用激光治疗无伴脱离或修补视网膜疾病编码14.2402。结论临床医师规范病案书写,编码员熟悉眼科编码规则,掌握较为全面的医学知识,正确理解每一个手术名称代表的内在含义,才能提高编码的准确性。Objective To analyze the existing problems in and find the causes for coding the anterior macular membrane related surgeries so as to improve the accuracy of coding.Methods Macular epiretinal membrane was classified anatomically,pathophysiologically,and etiologically and analyzed from the perspective of therapeutic therapies to identify and analyze the errors of its coding in the National Surgical Procedure Code-3.0 of the International Classification of Disease-9(ICD-9-CM3)by way of case analysis.Results The errors were identified in such codes as 14.2900x002 for macular epiretinal membrane peeling,14.9x05 for subretinal membrane removal with surgical incision of retina,14.2900x004 for macular edema and macular epiretinal limiting membrane peeling because the coding of internal limiting membrane peeling is subject to the nature of macular disease,14.3901 for internal limiting membrane peeling of macular hole,and 14.2402 for laser treatment for retinal detachment or repair.Conclusion In order to improve the accuracy of coding,clinicians should standardize the writing of medical records,and coders should be familiar with the coding rules of ophthalmology,master systematic medical knowledge and correctly understand the actual meaning of every name of surgical operations.

关 键 词：黄斑前膜相关手术 国家临床3.0版ICD-9-CM-3 编码 案例 

分 类 号：R197.323.1[医药卫生—卫生事业管理] R774.5[医药卫生—公共卫生与预防医学]