马蹄内翻足手术编码分析  

Coding Analysis of Equinovarus Surgery

作　　者：牙丽绵 陈俊伟 Ya Limian;Chen Junwei(Jiangbin Hospital of Guangxi Zhuang Autonomous Region,Nanning 530021,Guangxi Zhuang Autonomous Region,China)

机构地区：[1]广西壮族自治区江滨医院,广西壮族自治区南宁市530021 [2]遵义医科大学附属医院,贵州省遵义市563003

出　　处：《中国病案》2025年第1期35-38,共4页Chinese Medical Record

摘　　要：马蹄内翻足是以足底向内翻转为特征的肢体异常,其手术治疗措施通常需要行骨或软组织结构的手术矫正,且不同的手术方式对应的编码有所不同,编码员面对复杂的手术过程,容易存在错编漏编的情况。通过归纳马蹄内翻足的临床分型和手术方式,利用ICD-9-CM-3索引原则对相关编码进行分析,汇总出马蹄内翻足手术操作编码通常涉及足关节融合(81.12/81.13)、跗骨/跖骨截骨术(77.28/77.38)、外固定支架固定术(78.1-)、外固定应用系统(84.71-84.73)、足软组织松解术(83.85/83.89/83.13)以及肌腱转位术(83.75)。不同临床术式存在不同的手术操作编码组合,编码员需掌握临床专业知识,保持与临床医师的良好沟通,借助工具书索引信息区分相似编码之间的不同,把握手术操作编码的分类内涵,从而进一步提高编码质量。Equinovarus is a limb abnormality characterized by an inward turning of the sole, and its surgical treatment usually requires correction of bone or soft tissue structures. Different surgical methods correspond to different codes, and coders are prone to errors and omissions due to the complexity of the surgical process. By summarizing the clinical classification and surgical methods for equinovarus and applying the ICD-9-CM-3indexing principles to analyze relevant surgical coding, it is concluded that surgical coding for equinovarus usually involves foot joint fusion(81.12/81.13), tarsal osteotomy(77.28/77.38), external fixation with stent fixation(78.1-), external fixation application system(84.71-84.73), foot soft tissue release surgery(83.8-/83.14),and tendon transfer or transplantation(83.75). Different clinical procedures require specific combinations of surgical operation codes. Coders should develop clinical expertise, maintain effective communication with clinicians, differentiate similar codes using reference book index information, and understand the classification nuances of surgical operation codes to further improve coding quality.

关 键 词：马蹄内翻足 手术编码 ICD-9-CM-312 

分 类 号：R197.3[医药卫生—卫生事业管理]