慢性化脓性中耳炎疾病及手术编码讨论  

Discussion on Chronic Suppurative Otitis Media Disease and Surgical Coding

作　　者：何佳婧 莫春梅[1] He Jiajing;Mo Chunmei(Department of Medical Records,West China Hospital of Sichuan University,Chengdu 610041,Sichuan Province,China)

机构地区：[1]四川大学华西医院,四川省成都市610000

出　　处：《中国病案》2024年第4期29-31,共3页Chinese Medical Record

摘　　要：慢性化脓性中耳炎是常见的耳科疾病,根据病理和临床表现分为单纯型、胆脂瘤型和骨疡型,目前最常见的治疗方法为:通过乳突手术清除中耳病灶以及通过鼓室成形术重建中耳传音结构。乳突手术具体类型分为:乳突根治术、完壁式乳突根治术、开放式乳突根治术、完桥式乳突根治术和上鼓室鼓窦切开术,其对应ICD-9-CM-3编码分别为:20.42、20.4900x009、20.4900x008、20.4901和20.4900x007,鼓室成形术按照Wullstein-Zollner分类法的分为五型,其编码为:Ⅰ型19.4,Ⅱ型19.52、Ⅲ型19.53、Ⅳ型19.54和Ⅴ型19.55,其它重要的手术操作,如外耳道成形术18.6,需按照实际情况进行编码。编码员应熟练掌握相关疾病和手术编码及其内涵,同时加强相关临床知识的学习,与临床医师沟通,提高编码质量,从而保证编码的准确性。Chronic suppurative otitis media is a common ear disease,which can be divided into simple type,cholesteatoma type and caries type according to the pathological and clinical manifestations.Mastoid surgery aimed at clearing the middle ear lesions and tympanoplasty aimed at reconstructing the middle ear sound transmission structure are the most common treatment methods at present.The specific types of mastoidectomy are:radical mastoidectomy,complete wall mastoidectomy,open mastoidectomy,complete bridge mastoidectomy,and tympanoplasty,and the corresponding ICD-9-CM-3 codes are:20.42,20.4900x009,20.4900x008,20.4901 and 20.4900x007,tympanoplasty is classified into five types according to the Wullstein-Zollner classification system,with codes of type Ⅰ 19.4,type Ⅱ 19.52,type Ⅲ 19.53,type IV 19.54,and type V 19.55.Other important surgical procedures,such as external auditory canal shaping surgery 18.6,need to be coded according to the actual situation.Coders should be proficient in mastering relevant disease and surgical codes and their connotations,while strengthening the learning of relevant clinical knowledge,communicating with clinical physicians,and improving the quality of coding to ensure the accuracy of coding.

关 键 词：慢性化脓性中耳炎 乳突根治术 鼓室成形术 手术编码 疾病编码 

分 类 号：R764.9[医药卫生—耳鼻咽喉科]