保留乳房的乳腺癌切除术ICD-9-CM-3编码探讨  

Study on ICD-9-CM-3 Coding in Breast-conserving Breast Resection

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作  者:覃华凌 陆田田 陆丹艳[1] Qin Hualing;Lu Tiantian;Lu Danyan(Guangxi Guigang People's Hospital,Guigang 537100,China;不详)

机构地区:[1]贵港市人民医院,广西壮族自治区贵港市537100

出  处:《中国病案》2023年第5期29-31,共3页Chinese Medical Record

基  金:广西壮族自治区卫生健康委员会自筹经费科研课题(Z-R20221947)。

摘  要:保留乳房的乳腺癌切除术为乳腺外科常见手术,包括乳房肿瘤完整切除术,乳房局部切除术和乳房象限切除术。文章通过分析乳腺癌保乳术临床实际应用案例,梳理编码思路和方法,提高编码员对保留乳房的乳腺癌切除术编码的准确性。根据ICD-9-CM-3分类规则,乳腺癌保乳术是以手术切除范围为轴心进行分类,分别为:乳房病损切除术85.21、乳房部分切除术85.23和乳房象限切除术85.22。术中前哨淋巴结活检情况是影响手术进展的关键指标,编码员在编码乳腺癌保乳术时,要明确手术切除方式,注意是否行腋窝淋巴结清扫。编码员通过加强自身临床知识储备,积极与专科医师沟通,是提高编码准确性和完整性的有效途径。Breast-conserving mastectomy is a common procedure in breast surgery,including lumpectomy,partial mastectomy and quadrantectomy.By analyzing the clinical application cases of breast-conserving surgery for breast cancer,this article sorts out the coding ideas and methods,and improves the coding accuracy of coders for breast-conserving mastectomy.According to the ICD-9-CM-3 classification rules,breast-conserving surgery for breast cancer is classified based on the scope of surgical resection,which are:lesion resection 85.21,partial mastectomy 85.23 and quadrant resection 85.22.Intraoperative sentinel lymph node biopsy is a key indicator affecting surgical progress.When coders code breast-conserving surgery for breast cancer,they should clarify the surgical resection method and pay attention to whether axillary lymph node dissection is performed.Strengthening one's own clinical knowledge reserves and actively communicating with specialists are effective ways to improve the accuracy and completeness of coders'breast-conserving surgery coding.

关 键 词:乳腺癌 保留乳房的乳腺癌切除术 ICD-9-CM-3 手术编码 

分 类 号:R737.9[医药卫生—肿瘤] R197.323[医药卫生—临床医学]

 

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