先天性胆管扩张症ICD-9-CM-3手术编码探讨  

Discussion on the Operation Coding of ICD-9-CM-3 for Congenital Bile Duct Dilatation

作　　者：池梼 陈哲 唐腾骞 吴涛涛 曹永 李洪璇 Chi Tao;Chen Zhe;Tang Tengqian;Wu Taotao;Cao Yong;Li Hongxuan(Department of Quality Management,The First Affiliated Hospital of Army Military Medical University,Chongqing 400038,Sichuan Province,China;不详)

机构地区：[1]陆军军医大学第一附属医院,重庆市400038

出　　处：《中国病案》2024年第10期53-55,共3页Chinese Medical Record

摘　　要：先天性胆管扩张症分型复杂、手术方式专业性强,编码难点多。Todani分型是最常用的分型方式,它将先天性胆管扩张症分为五种类型,不同的临床分型将制定不同的手术方式。Ⅰ、Ⅱ、Ⅲ、Ⅳb型的常见手术方式需要根据切除扩张胆管的范围,编码为51.63和51.69;胆道重建需要根据吻合部位进行编码,即胆总管空肠吻合术编码为51.36,肝管空肠吻合术编码为51.37,胆管空肠吻合术(肝内)编码为51.39;Ⅳa和Ⅴ型常见手术方式根据肝脏的切除术范围编码为50.22或者50.3,腹腔镜机器人辅助操作需要编码17.42;肝移植术编码为50.5,附加供肝来源的编码为00.91-00.93。编码员在工作中必须通读病案,明确先天性胆管扩张症的分型、手术切除范围以及胆道的重建方式,熟练掌握省略编码和另编码原则,结合案例难点分析,进一步提高先天性胆管扩张症的手术编码准确率。The classification of congenital biliary dilatation is complex,the mode of operation is professional,and there are many difficulties in coding.Todani classification is the most commonly used classification method,it divides congenital bile duct dilatation into five types,different clinical classification will develop different surgical methods.The common surgical procedures of type I,Ⅱ,III and IVb need to be coded according to the extent of resection and dilatation of bile duct,and the reconstruction of bile duct needs to be coded according to the site of anastomosis,that is,the code for choledochojejunostomy is 51.36,the code for hepatojejunostomy is 51.37,and the code for choledochojejunostomy(intrahepatic)is 51.39.The codes of lVa and V-type common surgical procedures are 50.22 or 50.3 according to the scope of hepatectomy,17.42 for laparoscopic robot-assisted operation,50.5 for liver transplantation and 00.91-00.93 for additional donor liver.In their work,the coding staff must read through the medical records,define the classification of congenital bile duct dilatation,the scope of surgical resection and the mode of bile duct reconstruction,and skillfully master the principles of ellipsis coding and other coding,combined with the analysis of the difficulties of the case.to further improve the accuracy of surgical coding for congenital bile duct dilatation.

关 键 词：先天性胆管扩张症 手术编码 ICD-9-CM-3 

分 类 号：R657.4[医药卫生—外科学] R197.323[医药卫生—临床医学]