盆腔器官脱垂ICD-10编码分析  

ICD-10 coding of pelvic organ prolapse

作　　者：杨文珊 尹劲峰 王洁 李晨露 YANG Wenshan;YIN Jingfeng;WANG Jie;LI Chenlu(Longhua People’s Hospital,Shenzhen 518109,China)

机构地区：[1]深圳市龙华区人民医院,广东深圳518109

出　　处：《现代医院》2024年第9期1388-1390,共3页Modern Hospitals

摘　　要：目的准确编码盆腔器官脱垂,确保数据准确。方法结合国际疾病分类的专业知识和盆腔器官脱垂具体临床案例进行ICD-10编码分析。结果阴道前壁脱垂,不管严重程度如何都编码到N81.1;阴道后壁脱垂,不管严重程度如何都编码到N81.6;子宫脱垂Ⅰ度和Ⅱ度,不管是否合并阴道前壁和后壁脱垂都编码到N81.2;子宫脱垂Ⅲ度,不管是否合并阴道前后壁脱垂以及前后壁脱垂严重程度如何都编码到N81.3;宫颈脱垂,不管严重程度如何、是否合并阴道前后壁脱垂、合并的阴道前后壁脱垂如何都编码到N81.2。另外,N81.-编码中不包括生殖器脱垂合并妊娠、临产或分娩(O34.5),卵巢和输卵管脱垂和疝(N83.4),子宫切除术后阴道穹隆脱垂(N99.3)。结论编码规则中的合并编码的规则需核对卷一才能准确编码,ICD-10中不能反映临床中阴道前后壁脱垂的严重程度,如需反映严重程度需在N81.-段扩展编码。编码员只有积极学习临床知识、巩固专业知识、加强责任心,才能提高编码水平,确保数据准确。Objective To accurately encode pelvic organ prolapse and ensure data accuracy.Methods ICD-10 coding analysis was performed in combination with the professional knowledge of the International Classification of Diseases(ICD-10)and specific clinical cases of pelvic organ prolapse.Results Vaginal anterior wall prolapse,regardless of severity,was encoded as N81.1;vaginal posterior wall prolapse,regardless of severity,as N81.6;uterine prolapse grade I and II,regardless of the presence or absence of vaginal anterior and posterior wall prolapse,as N81.2;uterine prolapse grade III,whether the prolapse of the anterior and posterior vaginal walls is combined,or what level of the severity of the prolapse,as N81.3;cervical prolapse staging,regardless of severity or presence of vaginal anterior and posterior wall prolapse,as N81.2.In addition,the N81.-code does not include genital prolapse complicating pregnancy(O34.5),prolapse and hernia of ovary and fallopian tube(N83.4),vaginal fornix prolapse after hysterectomy(N99.3).Conclusion To ensure accurate coding,the composite coding rules must be cross-checked with volume one.ICD-10 failed to reflect the severity of vaginal prolapse in clinical practice.To consider the severity,coding should be extended in the N81.-segment.It is essential for coders to actively acquire clinical knowledge,reinforce professional knowledge,and enhance their responsibility to improve their coding proficiency and ensure data accuracy.

关 键 词：盆腔器官脱垂 盆腔器官脱垂临床分度 子宫颈脱垂 ICD-10 编码分析 

分 类 号：R197.323.1[医药卫生—卫生事业管理]