ICD-10中Z编码的正确使用  

Accurate Application of Z Coding in ICD-10

作　　者：周蒙 张鑫 于爽[1] Zhou Meng;Zhang Xin;Yu Shuang(Qingdao Municipal Hospital,Qingdao 266011,Shandong Province,China;不详)

机构地区：[1]青岛市市立医院,山东省青岛市266011

出　　处：《中国病案》2024年第6期45-48,共4页Chinese Medical Record

摘　　要：分析ICD-10中Z00-Z99编码的概念及使用特点,并将Z编码分为8种类型,分别是检查和调查类、具有潜在健康危害的人、针对传染病采取免疫治疗类、说明操作未执行原因类、预防性措施或手术类、生殖有关情况与保健机构接触的人、为特殊操作和卫生保健而与保健机构接触的人、因其他情况而与保健机构接触的人。同时根据编码原则以及《住院病案首页数据填写质量规范(暂行)》《医疗保障基金结算清单填写规范》等文件要求,整理归纳出不应作为主要诊断的Z编码,并提供主要诊断选择的建议。在医疗机构中,Z28免疫治疗未进行、Z33附带妊娠状态、Z37-Z38分娩的结局、Z40.9未特指的预防性手术、Z53为特殊操作而作为保健机构接触的人,但操作未进行、Z80-Z99具有与家族和个人史以及影响健康状态的某些情况有关的潜在健康危害的人不应作为主要诊断。编码员应熟练掌握规则,将理论与实践相结合,不断更新最新知识,提高自身综合素质,以实现编码准确率的稳步提升。The concept and application characteristics of Z00-Z99 coding in ICD-10 are analyzed,and Z coding is divided into eight types.They are examinations and investigations,persons with potential health hazards,persons taking immunotherapy for infectious diseases,persons explaining the reasons for not performing operations,preventive measures or operations,persons contacting health institutions in relation to reproduction,persons contacting health institutions for special operations and health care,persons contacting health institutions for other circumstances.At the same time,according to the coding principles and the requirements of"Quality Specification for filling in the first page Data of Inpatient Medical Records(Interim)"and"filling in the Medical Security Fund settlement List"and other documents,the Z-code that should not be used as the main diagnosis is summarized,and suggestions for the selection of the main diagnosis are provided.In medical facilities,Z28 immunotherapy not performed,Z33 incidental pregnancy status,Z37-Z38 outcome of delivery,Z40.9 not specifically referred to preventive surgery,Z53 for a specific procedure as a health care facility contact,but the procedure was not performed,Z80-Z99 related to family and personal history and certain conditions affecting health status should not be used as the primary diagnosis.Coders should master the rules,combine theory with practice,constantly update the latest knowledge,improve their overall quality,in order to achieve steady improvement of coding accuracy.

关 键 词：Z编码 住院病案首页 ICD-10 

分 类 号：R197.323[医药卫生—卫生事业管理]