指伸肌腱损伤修复术案例编码讨论  

Discussion on Case Coding of Repair of Finger Extensor Tendon Injury

作　　者：王俊伟[1] Wang Junwei(970 Hospital of PLA,Yantai 264000,China)

机构地区：[1]中国人民解放军第九七〇医院,山东省烟台市264000

出　　处：《中国病案》2023年第5期32-34,共3页Chinese Medical Record

摘　　要：手部肌腱损伤有多种类型,医师针对具体损伤情况采用不同的肌腱修补术式。指伸肌腱I区断裂,附着点有部分肌腱断端残留时,可进行直接缝合;肌腱自止点处撕脱而又无撕脱骨片或撕脱骨块细小、碎裂或撕脱远端肌腱不足2mm,或断端撕裂较重不整齐者以及陈旧性损伤远断端无明显腱性部分时,需要重建肌腱止点;肌腱缺损严重时,需行肌腱移植或肌腱转位。常用的指伸肌腱损伤术式有肌腱缝合术、止点再附着术、移植术、移位术、整形术等。肌腱缝合术编码为82.45;肌腱再附着编码为82.53;肌腱移植术编码为82.56;肌腱移位术编码为82.57;手的整修术无移植物编码为82.84或82.85,使用移植物编码为82.79。There are many types of tendon injuries in the hand.Physicians use different tendon repair procedures for specific injuries.When the finger extensor tendon I area is ruptured,and some tendon stumps remain at the attachment point,a direct suture can be performed.When the tendon is avulsed from the insertion point and there is no avulsion bone fragment or the avulsion bone fragment is small,fragmented or the avulsion of the distal tendon is less than 2mm,or when the tear of the stump is heavy and irregular,and there is no obvious tendinous part at the distal stump of the old injury,reconstruction of tendon insertion is required.When the tendon defect is severe,a tendon graft or tendon transposition is required.Coders need to be proficient in coding knowledge,accumulate experience in work,judge specific surgical procedures by reading surgical records,and give correct codes.Commonly used finger extensor tendon injuries include tendon sutures,insertion reattachment,transplantation,displacement,and plastic surgery.Tendon sutures are coded as 82.45.Tendon reattachment is coded as 82.53.Tendon grafts are coded as 82.56.Tendon transfers are coded as 82.57.Revisions of the hand are coded 82.84 or 82.85 without grafts and 82.79 with grafts.

关 键 词：指伸肌腱损伤 修补术 ICD-9-CM-3 编码 

分 类 号：R687.2[医药卫生—骨科学] R197.323[医药卫生—外科学]