4例肿瘤诊断ICD-10编码探讨  

ICD-10 Coding of 4 Cases of Tumor Diagnosis

作　　者：贺晓辉[1] 王学利 He Xiaohui;Wang Xueli(Chongqing University Fuling Hospital,Chongqing 408000,China)

机构地区：[1]重庆大学附属涪陵医院,重庆市408000

出　　处：《中国病案》2023年第6期53-56,共4页Chinese Medical Record

摘　　要：文章通过临床实践中遇到的4例肿瘤诊断疑难编码,按照ICD-10肿瘤编码查找方法,运用ICD-10与ICD-O-3的转换知识,确定阑尾黏液性肿瘤(M8480/1)、软组织多形性玻璃样变血管扩张性肿瘤(M8802/1)、角化棘皮瘤(M8071/3)、肉瘤型颗粒细胞瘤(M8620/3)的形态学编码,结合病案并运用编码规则最终确定4例肿瘤诊断的编码。通过4例肿瘤诊断疑难编码案例,尝试归纳肿瘤诊断编码特点和其中的难点问题,并希望找到切实可行的解决办法。建议编码员正确熟练掌握编码规则和编码方法步骤,丰富WHO肿瘤组织学分类等专业相关知识,学会阅读分析病案,在加强临床医学知识的学习的同时,加强与临床及病理医师沟通协作,努力提高肿瘤诊断疑难编码编码的准确性,在ICD-10更新不及时的情况下,切实规范管理并加强编码工作。In this paper,4 cases of difficult tumor diagnosis coding encountered in clinical practice,according to the ICD-10 tumor coding search method,using the conversion knowledge of ICD-10 and ICD-O-3,The morphological codes of appendicular mucinous tumor(M8480/1),soft tissue pleomorphic hyalinoid vasodilator tumor(M8802/1),keratoacanthosis(M8071/3)and sarcomatous granulocytoma(M8620/3)were determined,and the diagnostic codes of 4 tumors were finally determined by combining medical records and using coding rules.Through 4 cases of difficult coding in tumor diagnosis,this paper attempts to summarize the characteristics and difficult problems of tumor diagnosis coding,and hopes to find practical solutions.It is recommended that coders correctly master the coding rules and coding methods and procedures,enrich the professional knowledge of WHO tumor histology and classification,learn to read and analyze medical records,strengthen the communication and cooperation with clinicians and pathologists while strengthening the study of clinical medical knowledge,strive to improve the accuracy of the difficult coding of tumor diagnosis, and effectively standardize management andstrengthen coding work if ICD-10 is not updated in time.

关 键 词：ICD-10 阑尾黏液性肿瘤 软组织多形性玻璃样变血管扩张性肿瘤 角化棘皮瘤 肉瘤型颗粒细胞瘤 

分 类 号：R730.4[医药卫生—肿瘤] R197.323[医药卫生—临床医学]