2022年某医院阑尾炎国际疾病分类编码质量分析  

Quality analysis of ICD code for appendicitis in a hospital in 2022

作　　者：马迎丽 Ma Yingli(Binzhou Medical Univesity Hospital,Binzhou 256603,China)

机构地区：[1]滨州医学院附属医院,山东滨州256603

出　　处：《中国医院统计》2024年第2期149-152,共4页Chinese Journal of Hospital Statistics

摘　　要：目的分析阑尾炎国际疾病分类编码质量,为医保支付方式改革提供理论依据。方法由2名具有病案信息技术中级职称的编码员和1名胃肠外科主治医师组成编码质控小组,检索我院2022年医保结算数据中阑尾炎患者病案,逐一对病案审核分析,对编码错误病案重新编码。采用Excel记录阑尾炎错误类型,进行统计分析。结果我院2022年阑尾炎出院病案630份,编码错误病案154份,编码错误率24.44%。其中未依据病理结果修正主要诊断的病案87份,占比56.49%,未采用合并编码占比22.73%,未区分阑尾炎急性、慢性占比18.83%,其他1.95%。结论医疗机构需加强对病案编码质量的督导力度;编码员需加强编码理论知识及相关临床知识学习,切实提高业务素质;临床医师应规范书写诊断及相关医疗文书,为编码准确性做好基础工作。Objective To analyze the coding quality of ICD for appendicitis and provide theoretical basis for the reform of medical insurance payment methods.Methods A coding quality control team consisting of 2 coding personnel with intermediate titles in medical record information technology and 1 attending physician in gastrointestinal surgery was formed to retrieve the medical insurance settlement data of appendicitis patients in the hospital in 2022.The medical records were reviewed and analyzed one by one,and the coding errors were recoded.Excel was used to record error types of appendicitis for statistical analysis.Results The number of appendicitis discharge cases in 2022 was 630,and the number of coding error cases was 154,with a coding error rate of 24.44%.Among them,87 cases(56.49%)were not corrected according to pathological results,22.73%were not combined with coding,18.83%were acute and chronic appendicitis,and 1.95%were not distinguished.Conclusion Medical institutions need to strengthen the supervision of the quality of medical record coding.Coders should strengthen the study of coding theory and related clinical knowledge to improve the quality of coders.Clinicians should standardize the writing of diagnosis and related medical documents to do the basic work for the accuracy of coding.

关 键 词：阑尾炎 ICD编码质量 编码错误 病理结果 

分 类 号：R656.8[医药卫生—外科学] R197.323[医药卫生—临床医学]