隐匿型肾炎的疾病编码探讨  

Discussion on Disease Coding of Cryptic Nephritis

作　　者：杨燕媚[1] Yang Yanmei(Huizhou Central People's Hospital,Huizhou 516000,Guangdong Province,China)

机构地区：[1]惠州市中心人民医院,广东省惠州市516000

出　　处：《中国病案》2024年第12期34-36,共3页Chinese Medical Record

摘　　要：隐匿型肾炎编码首先要区分其临床症状,根据不同的临床症状选择合适的主导词在第三卷查找,再核对第一卷。结合ICD-10编码查找及核对所得:临床表现为血尿,编码分类于N02,无症状性蛋白尿,编码为N06,无症状性血尿和蛋白尿,分类于N03。其次要明确病理分类于ICD-10亚目直接的关系。另外,隐匿型肾炎准确编码还需要注意区分以下相关概念,一是特发性血尿和蛋白尿,需要区分其是否肾小球源性;二是掌握IgA肾病,主要临床表现是血尿,依靠肾活检免疫病理学进行诊断,虽然编码同样分类于N02,但有别于隐匿型肾炎的血尿,三是区别病理报告的“膜性”、“系膜增生性”和“膜增生性”概念。清晰掌握以上概念,明确隐匿型肾炎编码思路,编码员加强学习,规范临床住院病案首页诊断填写,才能正确编码,提高编码准确性和编码质量。Occult glomerulonephritis coding should first distinguish its clinical symptoms, according to different clinical symptoms to choose the appropriate leading word in the third volume to find, and then check the first volume. According to ICD-10 codes, the clinical manifestation was hematuria, which was classified as N02,asymptomatic proteinuria, which was classified as N06, asymptomatic hematuria and proteinuria, which was classified as N03. Secondly, the direct relationship between pathological classification and ICD-10 suborder should be clarified. In addition, the accurate coding of latent glomerulonephritis needs to pay attention to distinguish the following related concepts, one is idiopathic hematuria and proteinuria, which need to distinguish whether they are of glomerular origin, the other is to master IgA nephropathy, the main clinical manifestation is hematuria, the diagnosis was made by renal biopsy immunopathology. Although the coding was also classified as N02, it was different from hematuria in occult nephritis, the third is to distinguish the concepts of "Membranous", "Mesangial hyperplasia" and "Membranous hyperplasia" in pathological reports. To master the above concepts clearly, to clarify the coding ideas of latent nephritis, to strengthen the study of coders, to standardize the filling of diagnosis on the front page of clinical medical records, we can correctly code and improve the accuracy and quality of coding.

关 键 词：隐匿性肾炎 ICD-10 编码 

分 类 号：R197.323[医药卫生—卫生事业管理]