多指畸形疾病与手术编码探讨  

Discussion on the Encoding of Polydactyly Disease and Operation

作　　者：王元雪 冶超 房学强 Wang Yuanxue;Ye Chao;Fang Xueqiang(The Affiliate Hospital of Chinese Medication Academe of Shandong,Jinan 250001,Shandong Province,China;不详)

机构地区：[1]山东省中医药研究院附属医院医务科,山东省济南市250001 [2]山东省妇幼保健院医务科,山东省济南市250001

出　　处：《中国病案》2024年第7期36-38,共3页Chinese Medical Record

摘　　要：多指畸形种类多,手术过程复杂。对多指畸形病案的疾病和手术编码过程进行梳理,结合临床案例,探讨如何提高多指畸形编码的准确性。首先根据多指的组织类型和部位确定疾病编码,皮下组织赘生指的疾病编码为Q82.8皮肤的其他特指先天性畸形,骨性结构的拇指多指为Q69.1副拇指,骨性结构的小指/中轴多指为Q69.0副指。伴并指畸形时需合并编码为Q70.4多指和并指畸形。再根据疾病编码找到对应的主要手术编码,切除赘生指的手术编码为86.26皮肤附件结扎术,切除副拇指为84.02拇指截断术和拇指关节离断术,切除其他副指为84.01手指截断术和手指关节离断术。并注意同时编码术中进行的其他手术操作,主要有77.2楔形骨切开术(77.24为掌骨,77.29为指骨)、80.94关节的其他切除术、77.84其他部分骨切除术、82.69拇指的其他重建术、81.72掌指关节和指间关节成形术不伴植入、82.53手肌腱再附着、82.54手肌肉再附着等。There are many types of polydactyly and the surgical procedures are complicated.This study sorted out the disease and surgical coding process for polydactyly cases and aims to discuss methods for improving the accuracy of polydactyly coding by integrating clinical cases.Firstly,the disease code is determined based on tissue type and anatomical site of polydactyly.The disease code for polydactyly involving subcutaneous tissue is Q82.8,classified under other specified congenital malformations of the skin.The code for polydactyly of the thumb with bone and joint structure is Q69.1,categorized as accessory thumb(s).The code for polydactyly of fingers,excluding the thumb,with bone and joint structure is Q69.0,classified as accessory finger(s).When polydactyly is accompanied by syndactyly,the codes should be merged as Q70.4 polysyndactyly.Secondly,the corresponding major surgical operation code is identified based on the disease code.The surgical operation code for excision of polydactyly involving subcutaneous tissue is 86.26(ligation of dermal appendage).The code for excision of accessory thumb(s)is 84.02(amputation and disarticulation of thumb),and the code for excision of accessory finger(s)is 84.01(amputation and disarticulation of finger).Meanwhile,attention should be given to encoding other surgical operations performed during the surgery,including wedge osteotomy(77.24 for metacarpal,77.29 for phalange),other excision of joint(80.94),other partial ostectomy(77.84),other reconstruction of thumb(82.69),arthroplasty of metacarpophalangeal and interphalangeal joint without implant(81.72),reattachment of tendon of hand(82.53),reattachment of muscle of hand(82.54),and others.

关 键 词：多指畸形 疾病诊断编码 手术治疗编码 

分 类 号：R197.323[医药卫生—卫生事业管理]