先天性并指畸形疾病及手术操作编码分析  

Analysis of disease and surgical procedure coding for Congenital Syndactyly

作　　者：钟婷婷 陆田田 陆丹艳[1] Zhong Tingting;Lu Tiantian;Lu Danyan(Guigang People's Hospital,Guigang 537100,Guangxi Zhuang Autonomous Region,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8期28-30,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：对先天性并指畸形临床分类及手术修复方式进行归纳,结合典型案例,根据ICD编码规则分析编码思路,以提高疾病及手术操作编码准确率。先天性并指畸形疾病编码根据并指类型区分,单纯性并指畸形编码于Q70.1,骨性并指畸形编码于Q70.0,多指和并指畸形编码于Q70.4;手术编码则根据具体术式进行,单纯性并指分指术编码于86.85,骨性并指分指术编码于78.49;指蹼成形术编码于86.73;皮肤移植术根据移植皮肤的不同类型选择编码86.6-;术中进行的肌腱处理、关节重建等操作也应进行相应编码。编码员要仔细阅读病历,及时与临床医师沟通,准确区分并指类型及手术方式,严格遵循编码规则准确编码。The clinical classification and surgical repair methods of congenital syndactyly were summarized,and the coding ideas were analyzed according to the coding rules of ICD in combination with typical cases,so as to improve the coding accuracy of diseases and surgical operations.The codes of congenital syndactyly disorders were differentiated according to the type of syndactyly,simple syndactyly was coded in Q70.1,bony syndactyly was coded in Q70.0,and polydactyly syndactyly was coded in Q70.4.The code of operation was based on the specific operation type.The code of simple combined fingers and sub-fingers was 86.85,and the code of bone combined fingers and sub-fingers was 78.49.Finger web forming was coded at 86.73;Skin grafting according to the different types of skin graft selection code 86.6-;Intraoperative tendon manipulation,joint reconstruction and other operations should also be coded accordingly.Coders should carefully read medical records,timely communicate with clinicians,accurately distinguish and refer to types and surgical methods,and strictly follow coding rules for accurate coding.

关 键 词：先天性并指 并指分离 指蹼成形 皮肤移植 ICD编码 

分 类 号：R658.2[医药卫生—外科学] R197.323[医药卫生—临床医学]