1例脾组织植入的主要诊断选择和ICD编码  

The Selection of Primary Diagnosis and ICD Code for A Case of Splenosis

作　　者：张弘 王凯鹏 钟雪梅 庞倩云 荣维淇 尹世全 Zhang Hong;Wang Kaipeng;Zhong Xuemei;Pang Qianyun;Rong Weiqi;Yin Shiquan(Department of Medical Record,National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100021,China;不详)

机构地区：[1]国家癌症中心国家肿瘤临床医学研究中心中国医学科学院北京协和医学院肿瘤医院,北京市100021

出　　处：《中国病案》2023年第5期40-42,共3页Chinese Medical Record

基　　金：医院管理研究课题专项基金资助(LC2019D01)。

摘　　要：脾组织植入是因后天因素所致的一种疾病,特点是在各种解剖部位出现脾组织的自体植入,常被误诊或怀疑为恶性肿瘤,入院行手术后确诊。通过1例脾组织在肝脏和腹腔多发植入病例,分析主要诊断选择及其相应的ICD-10编码查找过程。当针对脾组织植入结节手术时,不论其植入部位或手术部位,均应以脾组织植入为主要诊断;其ICD-10编码查找的关键是选择脾组织植入为主导词,编码为D73.8,现行国家临床版2.0尚无具体对应编码,可选择D73.800脾的其他疾病,保证编码内涵准确,待编码库升级后再作统一调整。脾组织植入结节需与先天性副脾鉴别。因其中文翻译多种,使用工具书查找ICD-10编码时确定主导词较困难。仔细阅读病案和积极查阅文献,有助于主要诊断和ICD编码的准确选择。Splenosis is a disease caused by acquired factors(such as trauma or splenectomy),which is characterized by autoimplantation of viable splenic tissue throughout various anatomic compartments.It is often misdiagnosed or suspected as a malignant tumor,and diagnosed by surgery.Based on a case of splenosis,the selection of main diagnosis and the search process of the corresponding ICD-10 code was analyzed.When splenic autoimplant nodule resection is performed,splenosis should be selected as the main diagnosis,regardless of its implantation site or operation site;The key to ICD-10 code search is to select"splenosis"as the keyword,and the code is D73.8.Since there is no corresponding code in the current ICD-10 code database of national clinical version 2.0,“D73.800 other diseases of spleen”can be selected first.Unified adjustments will be made after the ICD-10 code database is upgraded.Splenic autoimplant nodules should be differentiated from congenital accessory spleen.

关 键 词：主要诊断 国际疾病分类 脾组织植入 

分 类 号：R197.323[医药卫生—卫生事业管理] R551.1[医药卫生—公共卫生与预防医学]