恶性肿瘤C76类目常见编码错误案例分析  

Case Analysis of Common Coding Errors in the C76 Category of Malignant Tumors

作　　者：梁丹梅 卢婷[1] 龚小玲[1] 黄庆文 Liang Danmei;Lu Ting;Gong Xiaoling;Huang Qingwen(Medical Records Department,Guangxi Yulin First People’s Hospital,Yulin City 537000,Guangxi Zhuang Autonomous Region,China;不详)

机构地区：[1]广西玉林市第一人民医院病案科,广西壮族自治区玉林市537000

出　　处：《中国病案》2024年第3期27-29,共3页Chinese Medical Record

摘　　要：目的分析某医院近3年恶性肿瘤编码于C76类目(其他和不明确部位的恶性肿瘤)的典型错误案例,提高恶性肿瘤编码准确率。方法从住院病案首页管理系统中检索2020年1月1日-2022年12月31日3年期间主要诊断编码为C76类目的病案共53例,由3名编码员和1名病理科副主任医师,依据ICD肿瘤编码规则逐一核查。结果共有49份病案主要诊断编码错误使用C76类目,错误率为92.45%。修正后分类于以下几个类目:结缔组织和软组织恶性肿瘤、皮肤黑色素瘤和皮肤其他恶性肿瘤、口腔恶性肿瘤各12例,错误占比均为24.49%;女性生殖器官恶性肿瘤、淋巴结和其他部位的继发恶性肿瘤、结缔组织和其他软组织动态未定或动态未知的肿瘤各4例,错误占比均为8.16%;B-细胞淋巴瘤1例,错误占比为2.04%。结论主要诊断错误编码于C76类目的前3位发生在结缔组织和软组织恶性肿瘤、皮肤黑色素瘤和皮肤其他恶性肿瘤、口腔恶性肿瘤等病种,多为编码年资5年以下的编码员出现错误。部分临床医师书写不规范肿瘤诊断、编码员病理学和解剖学知识欠缺,不熟悉肿瘤编码规则和不认真阅读手术记录,是造成错误编码于C76类目的主要原因,加强肿瘤诊断书写和疾病编码的培训与质控是降低编码错误率的关键。Objectives This study aims to analyze typical error cases of malignant tumors coded in the C76 category(malignant tumors of other and unclear locations)in a hospital in the past three years to improve the accuracy of malignant tumor coding.Methods A total of 53 medical records with the main diagnosis code of C76 category during the three years from January 1,2020 to December 31,2022 were retrieved from the inpatient medical record front page management system.Three coders and one associate chief physician of the Department of Pathology checked each case one by one according to the ICD tumor coding rules.Results A total of 49 cases had major diagnostic coding errors using the C76 category,with an error rate of 92.45%.The corrections were classified into the following categories:There were 12 cases each of connective tissue and soft tissue malignant tumors,cutaneous melanoma and other malignant skin tumors,and oral malignant tumors,and the error proportions were all 24.49%;There were 4 cases each of malignant tumors of female reproductive organs,secondary malignant tumors of lymph nodes and other parts,and tumors of connective tissue and other soft tissues whose dynamics were undetermined or unknown,and the error ratio was 8.16%;There was 1 case of B-cell lymphoma,and the error rate was 2.04%.Conclusions The main diagnostic errors coded in the top 3 digits of the C76 category occur in connective tissue and soft tissue malignant tumors,skin melanoma and other malignant skin tumors,oral malignant tumors,etc.Most of the errors are made by coders with less than 5 years of coding experience.Some clinicians do not write standardized tumor diagnoses,coders lack knowledge of pathology and anatomy,are not familiar with tumor coding rules,and do not read surgical records carefully,which are the main reasons for incorrect coding in the C76 category.Strengthening training and quality control in tumor diagnosis writing and disease coding is the key to reducing coding error rates.

关 键 词：C76类目 解剖部位 肿瘤形态学 诊断书写 编码质量 

分 类 号：R730[医药卫生—肿瘤] R197.323[医药卫生—临床医学]