消化系统神经内分泌肿瘤编码错误分析  

Analysis on Miscoding of Neuroendocrine Tumors of Digestive System

作　　者：李晓鹏 殷小磊 李伟静 林梅[1] 张彬[1] 黄金丽 陈宁 李书梅[1] Li Xiaopeng;Yin Xiaolei;Li Weijing;Lin Mei;Zhang Bin;Huang Jinli;Chen Ning;Li Shumei(Department of Medical Records,The Fourth Hospital of Hebei Medical University,Shijiazhuang 050011,Hebei Province,China;不详)

机构地区：[1]河北医科大学第四医院病案科,河北省石家庄市050011 [2]河北医科大学第四医院消化内科,河北省石家庄市050011

出　　处：《中国病案》2023年第10期41-43,共3页Chinese Medical Record

基　　金：河北省医学科学研究重点课题(ZD20140471)。

摘　　要：目的分析某三甲医院消化系统神经内分泌肿瘤编码常见错误,提高编码准确率。方法检索该医院2020年1月1日至2021年12月31日病理诊断为消化系统神经内分泌肿瘤的病案,逐一核查,统计错误编码类型,总结编码经验。结果符合条件的病案共123份,有91份编码错误,错误率占73.98%。其中形态学编码被错误分类到/0良性肿瘤、/1动态未定或动态未知和/2原位癌中,错误分类到/1的占比最高,占错误编码的59.34%,相应的部位编码同时错误;将神经内分泌瘤错误分类到神经内分泌癌的占23.07%。结论消化系统神经内分泌肿瘤病理诊断知识更新迅速,编码员缺乏对新知识的了解,容易出现编码错误。编码员应该与病理科及临床科室沟通互动,及时更新知识体系,熟练掌握编码规则,以提高医院编码质量。Objective To improve the coding accuracy of neuroendocrine neoplasm of the digestive system by analyzing the coding errors of these tumors in a Three A and Tertiary Hospital.Methods From January 1st,2020 to December 31st,2021,the medical records of the hospital pathologically diagnosed as neuroendocrine tumors of the digestive system were retrieved,verified one by one,counted the types of miscoding,and summarized the coding experience.Results 123 eligible cases were retrieved in the whole hospital,among them 91 cases had coding errors,accounting for 73.98%.The morphological coding was misclassified into/0 benign tumors,/1 dynamic undetermined or dynamic unknown tumors and/2 carcinoma in situ.The highest proportion of them were misclassified to/1,reaching 59.34%of the total number of errors.The site coding was also misclassified correspondingly.Classification of neuroendocrine tumor as neuroendocrine carcinoma accounted for 23.07%of the total number of errors.Conclusions Because the pathological diagnosis knowledge of neuroendocrine neoplasm of the digestive system was updated rapidly,but the coders lack of clinical and pathological knowledge or did not have a deep understanding of the principles of international disease classification,which was prone to coding errors.Therefore,coders should communicate with clinical and pathology departments,update knowledge and be proficient in coding principles to improve the quality of coding.

关 键 词：神经内分泌肿瘤 消化系统 国际疾病肿瘤学分类 ICD-10编码 

分 类 号：R735[医药卫生—肿瘤] R197.323[医药卫生—临床医学]