ICD-9-CM-3中易被忽视的不包括编码案例分析  

Analysis of Excludes Coding Easily Neglected in ICD-9-CM-3

作　　者：孙玉[1] 秦晓静 刘炳麟[1] 孟伟光 Sun Yu;Qin Xiaojing;Liu Binglin;Meng Weiguang(Qingdao Municipal Hospital,Qingdao 266000,Shandong Province,China;不详)

机构地区：[1]青岛市市立医院,山东省青岛市266000

出　　处：《中国病案》2023年第9期42-45,共4页Chinese Medical Record

摘　　要：在ICD-9-CM-3的类目、亚目以及细目下,经常会有不包括的补充说明,编码员往往因为不熟悉临床相关专业知识,不认真核对类目表,过度依赖计算机检索系统而导致编码错误。利用病案统计管理系统检索出某三甲综合医院2021年7月1日-2022年6月30日手术术式为其他鼻甲切除术、经腹子宫全部切除术、膀胱造口术、鼻泪管探通术、阑尾切除术的病案共计792份,应用回顾性分析方法,对提取病案重新进行编码核查,统计编码错误率。结合相关手术操作案例,对上述5种涉及不包括的手术操作编码进行分析,其他鼻甲切除术21.69不包括鼻甲切除术伴鼻窦切除术;经腹子宫全部切除术68.4不包括根治性腹式子宫切除术,任何入路;膀胱造口术57.2不包括经皮膀胱造口术以及耻骨上膀胱造口术;鼻泪管探通术09.43不包括同时伴管或支架置入;阑尾切除术47.0不包括描述为附带阑尾切除术。分析错编不包括的原因,提出解决措施和方法。Under the categories,subdivisions,and details of ICD-9-CM-3,there are usually supplementary explanations of excludes.Coding errors often occur because coders are not familiar with clinical-related professional knowledge,do not check the catalog carefully,and rely excessively on computer retrieval systems.In this study,the medical records of 792 cases in a tertiary general hospital from July 1,2021 to June 30,2022 were retrieved using the medical record statistics management system,which included other turbinectomy,transabdominal hysterectomy,cystostomy,nasolacrimal duct exploration,and appendectomy.The retrospective analysis method was used to re-code the extracted medical records,and the coding error rate was counted.Combined with relevant operation cases,the code of operation involving excludes in the above 5 cases was analyzed.21.69 Other turbinectomy excludes turbinectomy with sinusectomy;68.4 Total transabdominal hysterectomy excludes radical abdominal hysterectomy which any approach;57.2 Cystostomy excludes percutaneous cystostomy and suprapubic cystostomy;09.43 Nasolacrimal duct probing excludes simultaneous placement of associated tubes or stents;47.0 Appendectomy excludes appendectomy described as incidental.The causes of wrong excludes were analyzed for proposing solutions.

关 键 词：ICD-9-CM-3 案例分析 不包括 

分 类 号：R197.323[医药卫生—卫生事业管理]