颅内静脉窦血栓形成的ICD-10编码探讨  

Exploration of ICD-10 Encoding in Intracranial Venous Sinus Thrombosis

作　　者：谭小燕[1] 尹龙燕[1] 陈贤展 Tan Xiaoyan;Yin Longyan;Chen Xianzhan(Guangzhou First People's Hospital,Guangzhou 510180,Guangdong Province,China;不详)

机构地区：[1]广州市第一人民医院,广东省广州市510180

出　　处：《中国病案》2024年第6期37-39,共3页Chinese Medical Record

摘　　要：颅内静脉窦血栓形成是一种缺血性脑血管疾病,它的发病原因复杂多样,在实际工作中容易产生错误编码。通过对颅内静脉窦血栓形成的编码整理,根据病因可分为炎性颅内静脉窦血栓形成GO8和非炎性颅内静脉窦血栓形成I67.6;流产并发症、妊娠期、产褥期的颅内静脉窦血栓形成应分类于第15章(妊娠、分娩、和产褥期疾病),分别编码于O03-O06中的.3或.8、O08.7、O22.5、O87.3;后遗症编码分类于G09、I69.8。通过案例分析其编码思路,针对不同的病因而给予正确的编码。要求临床医师规范书写病历,编码员要仔细阅读病案不断加强临床医学知识和编码知识,努力提升自身编码专业,加强与临床医师的沟通来提高编码准确性。Cerebral venous sinus thrombosis is a type of ischemic cerebrovascular disease with complex and diverse causes,which can easily lead to incorrect coding in practical work.By coding and organizing the formation of cerebral venous sinus thrombosis,it can be divided into inflammatory cerebral venous sinus thrombosis GO8 and non-inflammatory cerebral venous sinus thrombosis I67.6 based on the etiology.However,the immediate and outdated complications of abortion,as well as cerebral venous sinus thrombosis during pregnancy and puerperium,should be classified in Chapter 15(Pregnancy,Delivery,and Puerperal Diseases).The codes are O03-O06,O08.7,O22.5,O87.3,and the sequelae codes are classified as G09 and I69.8.Analyze its coding approach through case studies and provide correct coding for different etiologies.Clinical physicians are required to write medical records in a standardized manner.Coders should carefully read the medical records and continuously strengthen their clinical medical and coding knowledge,strive to improve their coding expertise,and strengthen communication with clinical physicians to improve coding accuracy.

关 键 词：颅内静脉窦血栓形成 案例 编码 

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