异常子宫出血主要诊断选择与ICD-10编码分析  

The Main Diagnostic Selection and ICD-10 Coding Analysis of Abnormal Uterine Bleeding

作　　者：徐峰 李梦楠 Xu Feng;Li Mengnan(Department of Medical Records Statistics,Chongqing Traditional Chinese Medicine Hospital,Jiangbei District,Chongqing 400021,China)

机构地区：[1]重庆市中医院病案统计科,重庆市400021 [2]重庆大学附属肿瘤医院病案管理科,重庆市400038

出　　处：《中国病案》2025年第1期38-40,共3页Chinese Medical Record

摘　　要：异常子宫出血病因分为9个类型,其病因可为单病因,也可为多病因。编码员在选择异常子宫出血病案主要诊断时,需遵守病因诊断优先原则。异常子宫出血病因诊断ICD-10编码为N84.0子宫体息肉、N80.0子宫的子宫内膜异位症、D25子宫平滑肌瘤、N85.1子宫内膜腺瘤性增生、C54.1子宫内膜恶性肿瘤,全身凝血相关疾病、子宫内膜局部异常、医源性三类疾病的编码需要明确具体疾病诊断,排卵障碍和未分类出血为N93.8和N93.9或根据出血的具体病因进行编码。导致错误编码发生的原因为编码员缺乏异常子宫出血临床专业知识的储备和病因诊断的敏感度,以及临床医师异常子宫出血诊断书写格式不规范。加强编码员异常子宫出血临床专业知识学习,并辅以信息化技术实现住院病案首页诊断描述功能,进而保证异常子宫出血病因诊断的正确选择以及ICD-10编码的精准性。The etiology of abnormal uterine bleeding can be divided into 9 types,which can be single etiology or multiple etiology.When selecting the main diagnosis for cases of abnormal uterine bleeding,coders must follow the principle of prioritizing etiological diagnosis.ICD-10 code for the diagnosis of abnormal uterine bleeding includes N84.0 uterine polyps,N80.0 endometriosis of the uterus,D25 uterine leiomyoma,N85.1 endometrial adenomatous hyperplasia,and C54.1 endometrial malignant tumor.The coding of systemic coagulation related diseases,local endometrial abnormalities,and iatrogenic diseases requires specific disease diagnosis.Ovulation disorders and unclassified bleeding are classified as N93.8 and N93.9 or coded according to the specific cause of bleeding.The reasons for the incorrect coding are the coders'lack of clinical expertise in abnormal uterine bleeding and the sensitivity of etiological diagnosis,as well as the non-standard writing format of clinical physicians for abnormal uterine bleeding diagnosis.Strengthen the learning of clinical professional knowledge of abnormal uterine bleeding for coders,and use information technology to realize the diagnosis description function on the front page,so as to ensure the correct selection of the diagnosis of the cause of abnormal uterine bleeding and the accuracy of ICD-10 coding.

关 键 词：异常子宫出血 主要诊断 病因诊断 ICD-10编码 

分 类 号：R711.52[医药卫生—妇产科学]