介入性超声手术操作编码分类探讨  

Discussion on Classification of Operation Codes in Interventional Ultrasound

作　　者：黄秀烟[1] HUANG Xiuyan(Medical Record Room,the First Affiliated Hospital of Fujian Medical University,Fuzhou Fujian 350005,China)

机构地区：[1]福建医科大学附属第一医院病案室,福建福州350005

出　　处：《中国卫生标准管理》2023年第6期10-17,共8页China Health Standard Management

摘　　要：当前,疾病编码作为国家数据已经在医院管理、绩效考核、院际交流、医保支付等不同领域发挥着重要作用,对编码的详细、准确性要求不断提高。国家卫生健康委发布的手术操作分类代码国家临床版3.0(2022修订)要求介入性超声作为首页操作必填项。编码员应根据手术操作编码的三大要素:疾病部位、手术方法、手术入路,选择正确的主导词查找编码,并核对编码,直至每个要素都涵盖并与实际操作贴合,才能得到一个正确且唯一的编码。本文按照国际疾病分类第9版临床修订本手术与操作(ICD-9-CM-3)2011版的编码原则,结合手术操作分类代码国家临床版3.0(2022修订),对各种超声引导下介入治疗的手术操作编码进行分类探讨,以期提高编码准确性,促进疾病编码的区域性统一,为国家数据库和疾病诊断相关分组(diagnosis related groups,DRGs)提供更准确可靠的数据。At present,as national data,disease coding has played an important role in different fields,such as hospital management,performance evaluation,inter-hospital communication,medical insurance payment,etc.,and the requirements for detailed and accurate coding have been continuously improved.Interventional ultrasound is required as a required item in the first page of the operation issued by the National Health Commission classification code of surgical operation:National Clinical Version 3.0(revised in 2022).The coder should search for the code according to the three main elements of the surgical operation code:the disease site,the surgical approach,select the correct leading words,and check the code until each element is covered and fitted with the actual operation,so as to obtain a correct and unique code.In accordance with the coding principles of the International Classification of Diseases,the ninth edition of the clinical revision of the operation and operation(ICD-9-CM-3),2011 edition,and in combination with the classification code of the operation,the national clinical Version 3.0(2022 revision),this paper classifies and discusses the operation codes of various ultrasound-guided interventional therapy,with a view to improving the coding accuracy,promoting the regional unification of the disease coding,and providing more accurate and reliable data for the National database and diagnosis related groups(DRGs).

关 键 词：介入性超声 手术操作编码 分类探讨 ICD-9-CM-3 国家临床版3.0 编码准确性 

分 类 号：R197[医药卫生—卫生事业管理]