消化系统多部位恶性肿瘤ICD-10编码案例分析  

ICD-10 coding of malignant tumors in multiple sites of the digestive system

作　　者：胡颖辉 孔德莹 闫学丽 汤瑞祥 HU Yinghui;KONG Deying;YAN Xueli;TANG Ruixiang(The First Affiliated Hospital of Xi’an Jiaotong University,Xi’an 710000,China)

机构地区：[1]西安交通大学第一附属医院,陕西西安710000

出　　处：《现代医院》2024年第11期1699-1701,共3页Modern Hospitals

基　　金：陕西省自然科学基础研究计划(2022JQ-884)。

摘　　要：消化系统多部位恶性肿瘤的编码涉及的编码规则较多。如果两个或两个以上恶性肿瘤的病理类型不同,归类到多原发恶性肿瘤C97,根据入院治疗目的选择主要诊断。如果在病案首页中医生有两个以上消化系统恶性肿瘤的诊断,恶性肿瘤的病理类型相同且原发部位不明确时,肿瘤部位不同编码原则不同:①如果为一个恶性肿瘤跨越了两个或两个以上相邻部位,且原发部位不明确,应归类到交搭跨越恶性肿瘤,根据肿瘤所在的位置选择不同的编码;②当两个或两个以上恶性肿瘤位于同一部位下不相邻的亚部位,应归类到该部位三位数类目的.9亚目中;③如果两个或两个以上恶性肿瘤在消化系统中位置不相邻,则归类到C26.9。在编码过程中,编码员应认真阅读病案资料、不断积累临床知识,加强与临床沟通,以提高编码的准确性。Coding malignant tumors in multiple sites within the digestive system involves some coding rules.When more than two malignant tumors present various pathologic types,they should be included in the code of C97,which indicates multiple primary malignancies,and should be categorized into a specific code under the category of C97 upon corresponding treatment purposes.For those malignant tumors in the digestive system presenting with the same pathological results but unidentified primary sites,which are diagnosed as more than two types of tumors and recorded on the first page of a medical record,they are coded according to their specific locations.The coding principles are as followed:①If a malignant tumor spans two or more adjacent sites with an unidentified primary origin,it should be classified as a cross-site malignant tumor and coded based on the tumor’s anatomical location.②If more than two malignant tumors are located in the separate parts of the same location,they should be coded with“.9”as a subheading of the three-digit category specific to the right location.③If more than two malignant tumors are not adjacent to each other in the digestive system,they should be classified to the code of C26.9.In the process of coding,coders should review case data thoroughly,enhance the accumulation of clinical knowledge,and strengthen communications with doctors,thereby enhancing coding precision.

关 键 词：消化系统多部位恶性肿瘤 ICD-10 疾病编码 案例分析 

分 类 号：R197.323.1[医药卫生—卫生事业管理]