冠状动脉介入手术编码的探讨  

Discussion on Coding of Percutaneous Coronary Intervention

作　　者：付闪闪 孙洁[1] 周海滨[1] 王诚诚 Fu Shanshan;Sun jie;Zhou Haibin;Wang Chengcheng(Medical Record Information Department,Liaocheng People's Hospital,Liaoche 252000,Shandong Province,China;不详)

机构地区：[1]聊城市人民医院病案信息科,山东省聊城市252000

出　　处：《中国病案》2023年第3期27-29,共3页Chinese Medical Record

摘　　要：常见的冠状动脉介入手术方式有经皮冠状动脉腔内成形术、支架置入术、冠状动脉内斑块旋切术/旋磨术、激光成形术和冠状动脉动脉血管内超声等。其中最常见的手术方式是冠状动脉内支架置入术,由于手术过程中的具体术式不同、所用冠状动脉支架类型及造影导管的类型不同,编码员需依据国际疾病分类第九版临床修订本手术与操作(ICD-9-CM-3,2011版)确定冠状动脉介入手术的编码规则,根据具体手术选择编码:冠状动脉支架置入术(36.06/36.07)、置入血管支架的数量(00.45-00.48),治疗血管的数量(00.40-00.43)、分叉血管操作(00.44)、经皮冠状动脉球囊扩张成形术(00.66)、冠状动脉造影术(88.55-88.57)、冠状动脉血管内超声(00.2400x001)和经皮冠状动脉旋磨术(17.5501)。利用心内科行冠状动脉支架置入术的病例,分析发现共性问题,选取具有代表性的病例来探讨不同术式的冠状动脉支架置入术准确的手术操作编码,旨在提高手术编码的准确性,从而保证住院病案首页基础数据质量。Common coronary intervention methods include percutaneous transluminal coronary angioplasty, stent placement, coronary atherectomy/rotary atherectomy, laser angioplasty and coronary artery intravascular ultrasound,etc. The most common procedure is coronary artery stenting. Because the specific operation method is different, and the types of coronary stent and angiography catheter used are different during the operation, coders need to determine the coding rules for coronary interventional procedures according to the ninth edition of the International Classification of Diseases Clinical Revision Surgery and Procedures(ICD-9-CM-3, 2011 edition), and select the code according to the specific operation: Coronary artery stenting(36.06/36.07), the number of implanted stents(00.45-00.48), the number of treated vessels(00.40-00.43), bifurcation operation(00.44), percutaneous coronary balloon dilatation surgery(00.66), coronary angiography(88.55-88.57), coronary intravascular ultrasound(00.2400x001) and percutaneous rotational atherectomy(17.5501). Cases of coronary artery stenting in Department of Cardiology are used to find common problems through analysis and select representative cases to discuss the accurate operation coding of coronary artery stenting in different surgical procedures, so as to improve surgical coding accuracy and therefore ensure the quality of the basic data on the front pages of inpatient medical records.

关 键 词：冠状动脉介入治疗 手术操作编码 ICD-9-CM-3 血管分叉部位 

分 类 号：R541.4[医药卫生—心血管疾病] R197.323[医药卫生—内科学]