脑动脉分支脑梗死ICD编码的探讨  

Discussion on ICD Coding of Acute Cerebral Infarction Caused by Branches of Cerebral Artery

作　　者：庄岚清 郑浩渠 刘玲 陈珊 李璋恒 Zhuang Lanqing;Zheng Haoqu;Liu Ling;Chen Shan;Li Zhangheng(Department of Medical Records,Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine,Zhuhai,Guangdong Province,519000,China;不详)

机构地区：[1]珠海市中西医结合医院,广东省珠海市519000 [2]珠海市中医病案质控中心,广东省珠海市519000

出　　处：《中国病案》2023年第11期32-34,79,共4页Chinese Medical Record

摘　　要：急性脑梗死发病率高,出院病例多。既往文献对脑动脉皮层支和中央支引起的脑梗死描述不清,ICD编码不统一。通过阐述目前已经达成的共识,分析说明小脑动脉的范围应包括小脑上动脉、小脑下前动脉、小脑下后动脉;纠正英文翻译的缺陷,指出cerebral arteries应翻译为脑的动脉;明确了入脑前动脉和大脑动脉中隐含的脑动脉皮层支和中央支;从而确定脑动脉分支等引起急性脑梗死的准确编码归属。同时指出在ICD-102019修订版中腔隙性脑梗死的准确编码。编码员在遇到疑难编码,除了从分类诊断的原则上探讨外,也应结合基础医学和临床医学、翻译等方面查找证据,综合判断。The incidence of acute cerebral infarction is high,and there are many medical records of discharge.Cerebral infarction caused by cortical and central branches of cerebral arteries was not clearly described in the previous literature,and the ICD codes were not uniform.By expounding the consensus reached at present,the analysis shows that the scope of the cerebellar artery should include the superior cerebellar artery,anterior inferior cerebellar artery,and posterior inferior cerebellar artery.This study points out the correct translation of the cerebral artery,identifies the hidden branch arteries entering the anterior cerebral artery and cerebral artery,and thus determines the accurate coding attribution of acute cerebral infarction caused by branches of the cerebral artery.At the same time,this article points out the accurate coding of lacunar infarction in ICD-102019 revision.When coders encounter difficult codes,they should not only discuss the principles of classified diagnosis but also find evidence and judge comprehensively in combination with basic medicine,clinical medicine,translation,and so on.

关 键 词：急性脑梗死 ICD编码 小脑动脉 皮质支 中央支 腔隙性脑梗死 

分 类 号：R743.3[医药卫生—神经病学与精神病学] R197.323[医药卫生—临床医学]