下肢动脉硬化闭塞并血栓形成及腔内介入治疗编码质量 分析  

Analysis of the coding quality of lower extremity arteriosclerosis occlusion with thrombosis and endovascular intervention

作　　者：李汶嘉 孔德莹 苟瑜坤 张欣欣[1] 许莹 LI Wenjia;KONG Deying;GOU Yukun;ZHANG Xinxin;XU Ying(First Affiliated Hospital of Xi’an Jiaotong University,Xi’an 710061,China)

机构地区：[1]西安交通大学第一附属医院,陕西西安710061

出　　处：《现代医院》2025年第3期379-381,共3页Modern Hospitals

基　　金：陕西省自然科学基础研究计划青年项目(S2024-JC-QN-0995);国家卫健委卫生健康统计工作高质量发展揭榜攻关项目;西安交通大学第一附属医院科研发展基金(2022RKX-08)。

摘　　要：目的通过分析下肢动脉硬化闭塞并血栓形成及腔内介入治疗的编码错误原因,探讨下肢动脉硬化闭塞并血栓形成作为主要诊断的编码及血腔内介入治疗的不同术式编码,提高编码准确率。方法检索某三甲医院2023年1月1日-12月31日出院病案中主要诊断编码为I70~I74、I77.1并伴有血管腔内介入治疗的病案首页,对主要诊断编码以及手术编码中的错误,进行分类和解读。结果在满足筛选标准的924份病历中,主要诊断的编码错误有41份,缺陷率为4.43%。其中,下肢动脉粥样硬化的编码错误率最高,占比为1.30%;主要手术编码错误46份,缺陷率为4.98%,其中经皮下肢动脉取栓术编码错误率最高;经过分析,造成编码错误的主要原因为编码员阅读病案不仔细。结论下肢动脉硬化闭塞并血栓形成主要诊断及腔内介入治疗手术编码错误率较高,需从学科和病种层面加强对临床医生和编码员的编码培训,加强两者的沟通交流,同时建立并完善质控和考核体系,以提高主要诊断及手术的填写和编码的正确率。Objective By analyzing the causes of coding errors of lower extremity arteriosclerosis occlusion with thrombosis and the endovascular intervention,explore the principle diagnosis and intervention coding rules to improve coding quality.Methods Inpatient medical records with the principle diagnosis codes of I70-I74 and I77 accompanied by endovascular interventional from January 1,2023 to December 31,2023 were retrieved from a tertiary hospital.A retrospective study was conducted to analyze the causes of coding errors.Results A total of 924 eligible cases were selected.There were 41 principle diagnosis coding errors,with an error rate of 4.43%,among which the lower limb atherosclerosis coding had the highest error rate,accounting for 1.30%.There were 46 intervention coding errors,with an error rate of 4.98%,among which the percutaneous thrombectomy had the highest error rate.The main reason for coding errors was insufficient reading of medical record.Conclusion The coding error rate of the principle diagnosis of lower extremity arteriosclerosis occlusion and the endovascular intervention were relatively high.Therefore,it is necessary to continuously strengthen the training of clinicians and coders,including the coding rules and clinical knowledge of specialized disciplines,actively communicate between coders and clinicians,establish a quality control and assessment system,so as to improve the coding quality.

关 键 词：下肢动脉硬化闭塞症并血栓形成 腔内介入治疗 疾病编码 手术编码 

分 类 号：R197.323.1[医药卫生—卫生事业管理]