颅内血肿清除术ICD编码与DRG入组分析  

Intracranial hematoma removal ICD coding and DRG group analysis

作　　者：雷玲 邓陈平 王耀玮 LEI Ling;DENG Chenping;WANG Yaowei(Mianyang Third People's Hospital,Mianyang 621000,China)

机构地区：[1]绵阳市第三人民医院,四川绵阳621000

出　　处：《现代医院》2024年第3期380-383,共4页Modern Hospitals

摘　　要：颅内出血的病例,编码员在编码中容易忽略其颅内出血的病因,是自发性颅内出血还是创伤引起的颅内出血,两者在ICD-10中的编码完全不同。前者编码时分类于I60~I62,后者编码时分类于S06。不同的病因在DRG入组时也会进入不同的DRG组。当明确病因时,颅内出血的部位要明确是蛛网膜下出血、或是硬脑膜外/下出血还是脑实质出血,因为在做颅内血肿清除时,不同的出血部位其在ICD-9-CM-3中的编码是不同的。硬脑膜外血肿清除分类于01.24,硬脑膜下或蛛网膜下血肿清除分类于01.31,脑实质内血肿清除分类于01.39。在进行颅内血肿清除术时根据术式不同通常分为锥颅术、颅骨钻孔引流术和传统开颅手术,这三种术式的手术过程具有明显区别,编码员需要理解3种术式各自特点,做到准确分类。在DRG分组时,疾病编码与手术编码不同所入的DRG组也将不同。通过了解颅内血肿清除术的定义与病因,分析颅内血肿清除术的编码思路,从而提高编码员专业能力和保障DRG数据的准确性。In the case of intracranial hemorrhage,coders tend to ignore the cause of intracranial hemorrhage in the coding,whether it is spontaneous intracranial hemorrhage or intracranial hemorrhage caused by trauma,and the coding of the two is completely different in ICD-10.The former is classified as I60-I62 while the latter is classified as S06.Different etiology will also enter different DRG groups when DRG is included.When determining the cause,the site of intracranial hemorrhage should be determined whether it is subarachnoid hemorrhage,or epidural/subdural hemorrhage or cerebral parenchymal hemorrhage,because different bleeding sites have different codes in ICD-9-CM-3 when performing blood removal in cranial swelling.The classification of epidural hematoma removal was on 01.24,subdural or subarachnoid hematoma removal was on 01.31,and intracerebral parenchymal hematoma removal was on 01.39.The removal of intracranial hematoma is usually divided into cone craniotomy,skull trepanation and drainage and traditional craniotomy according to different operation methods.The operation process of these three operations is obviously different,and coders need to understand the characteristics of the three operations to achieve accurate classification.In the DRG grouping,the disease code is different from the surgical code and the DRG group will be different.Through understanding the definition and etiology of intracranial hematoma removal,the coding ideas of intracranial hematoma removal were analyzed,so as to improve the professional ability of coders and ensure the accuracy of DRG data.

关 键 词：颅内出血 颅内血肿清除 ICD-10 ICD9-CM-3 DRGS 

分 类 号：R651.15[医药卫生—外科学]