歪鼻ICD-10编码分析  

Analysis of ICD-10 Coding for Deviated nose

作　　者：张义锣 莫春梅[1] Zhang Yiluo;Mo Chunmei(Department of Medical Records,West China Hospital of Sichuan University,Chengdu 610041,Sichuan Province,China;不详)

机构地区：[1]四川大学华西医院病案科,四川省成都市610041

出　　处：《中国病案》2024年第11期36-38,共3页Chinese Medical Record

摘　　要：歪鼻根据病因分为先天性歪鼻和后天性歪鼻,根据偏斜的组织类型分为骨性歪鼻、软骨性歪鼻及混合性歪鼻。歪鼻的类型复杂多样,不同类型的歪鼻分类所涉及的ICD-10编码和章节不同,在实际工作中容易出现编码错误。对不同类型的歪鼻进行编码分析,指出编码的易错点和难点。在遇到歪鼻的病例时,临床医师需明确歪鼻的病因及偏斜的组织类型,做出正确的疾病诊断;编码员需认真阅读病案,了解病变的解剖学、影像学等知识,并及时查阅编码工具书及临床教材,综合分析后得出准确编码。先天性歪鼻对应的ICD-10编码:骨性歪鼻Q30.8,软骨性歪鼻Q67.4;后天性歪鼻对应的ICD-10编码:骨性歪鼻M95.0,软骨性歪鼻J34.2,急性外伤性歪鼻S02.2。混合性歪鼻没有合并编码,需要同时编码骨性歪鼻及软骨性歪鼻才能完整描述。The types of deviated nose are complicated and diverse.Different types of deviated nose classification involve different ICD-10 codes and chapters.Therefore,coding errors are easy to occur in actual work.This study analyzes the coding of different types of crooked noses and points out the coding errors and difficulties.When encountering medical records of deviated nose,the clinicians should clearly indicate the cause and tissue type of deviated nose and make the correct diagnosis of the disease.Coders need to read medical records carefully,understand the anatomy,imaging and other knowledge of the lesions,and promptly consult coding reference books and clinical teaching materials to come up with accurate coding after comprehensive analysis.Deviated nose can be divided into congenital deviated nose and acquired deviated nose according to the etiology,and bone deviated nose,cartilaginous deviated nose and mixed deviated nose according to the tissue type of deviated nose.The ICD-10 codes corresponding to congenital crooked nose are bony deviated nose Q30.8 and cartilaginous deviated nose Q67.4.The ICD-10 codes corresponding to acquired crooked nose are bony deviated nose M95.0,cartilaginous deviated nose J34.2,and fracture of nasal bones S02.2.There is no combined code of mixed deviated nose,and it is necessary to encode both bony and cartilaginous deviated nose to fully describe it.

关 键 词：歪鼻 鼻中隔偏曲 ICD-10编码 

分 类 号：R765[医药卫生—耳鼻咽喉科] R197.323[医药卫生—临床医学]