DRG支付改革背景下脓毒症相关疾病ICD-10编码探讨  

Study on ICD-10 coding of sepsis related diseases in the context of DRG payment

作　　者：谢冰珏 唐路 佘颖[1] 汤婷婷 宋萍[1] XIE Bingjue;TANG Lu;SHE Ying;TANG Tingting;SONG Ping(Children’s Hospital of Chongqing Medical University,Chongqing 400014,China)

机构地区：[1]重庆医科大学附属儿童医院,重庆400014

出　　处：《现代医院》2025年第3期375-378,共4页Modern Hospitals

基　　金：重庆医科大学附属儿童医院儿童医疗保障创新研究示范基地项目(NCRCCHD-2019-HP-11)。

摘　　要：目的提高脓毒症相关疾病编码及主要诊断选择的正确性,保障病案首页及DRG数据质量。方法结合临床与国际疾病分类专业知识梳理脓毒症相关疾病概念及编码规则,结合病案首页与医保结算清单填报规范总结脓毒症主要诊断选择原则,并通过临床实际案例解析脓毒症编码思路。结果脓毒症病原体阴性或未明确分类至A41.9,病原体明确主要分类至A40~A41.8;新生儿脓毒症分类至P36;妊娠分娩产褥期脓毒症分类于O03~O08、O75.3、O85;手术或各种操作后的脓毒症分类于T80.2、T81.4、T88.0;伴有器官功能障碍需附加R65.1,伴有脓毒性休克需附加R57.2。脓毒症主要诊断选择遵循病因优先原则,编码时需明确病因和病原体。结论编码员在编码脓毒症相关疾病时,需掌握此类疾病相关临床知识与编码规则,仔细阅读病案,同时加强与临床医生沟通,才能提高编码与主要诊断选择的正确性,进而确保首页数据质量与DRG入组的准确性。Objective To enhance the accuracy of sepsis related disease coding and primary diagnosis selection,thereby ensuring the quality of medical record home page and DRG data.Methods Sepsis related disease concepts and coding rules have been reviewed by combining clinical and International Classification of Diseases(ICD-10)expertise.The main diagnostic selection principles of sepsis were summarized based on the filling criteria of the medical record home page and the medical insurance settlement list,and sepsis coding ideas were analyzed through clinical cases.Results Negative or unidentified pathogens are classified as A41.9,while sepsis with identified pathogens is mainly classified as A40-A41.8;sepsis of newborn is classified as P36;sepsis during pregnancy,childbirth and puerperium is respectively classified as O03-O08,O75.3,and O85;sepsis following surgery or operations is classified as T80.2,T81.4,or T88.0;sepsis with organ dysfunction or septic shock should be separately coded as R65.1 or R57.2.The main diagnostic selection of sepsis follows the principle of etiology priority,and the cause and pathogen of sepsis should be confirmed when coding.Conclusion Coders need to master the clinical knowledge and coding rules related to sepsis,read the medical records carefully and strengthen communication with doctors to enhance the accuracy of coding and improve the main diagnosis,thereby ensuring the quality of medical record home page and the accuracy of DRG grouping results.

关 键 词：脓毒症 败血症 ICD-10 

分 类 号：R197.323.1[医药卫生—卫生事业管理]