女性中肾管囊肿和副中肾管囊肿编码案例分析  

Case Analysis of Coding for Female's Mesonephric Duct Cyst and Paramesonephric Duct Cyst

作　　者：叶海林 蒋春燕 秦坤龙 Ye Hailin;Jiang Chunyan;Qin Kunlong(Department of Medical Records,The First People's Hospital of Qinzhou,Qinzhou 535009,Guangxi Zhuang Autonomous Region,China;不详)

机构地区：[1]钦州市第一人民医院病案科,广西壮族自治区钦州市535099

出　　处：《中国病案》2025年第2期35-37,共3页Chinese Medical Record

摘　　要：女性中肾管囊肿和副中肾管囊肿是女性生殖器囊肿中两类常见的先天性囊肿,编码时易与女性生殖器的后天性囊肿混淆。中肾管囊肿和副中肾管囊肿都以发病部位作为分类轴心,而疾病部位编码错误是另一个常见问题。根据肾管遗迹沿途分布的不同部位对ICD索引进行总结:输卵管囊肿分类于Q50.4;阔韧带囊肿分类于Q50.5;宫颈囊肿分类于Q51.6;子宫囊肿分类于Q51.8;阴道、处女膜分类于Q52.4。编码员临床知识不足、编码知识掌握不扎实、没有通读病案、过度依赖国家临床版字典库是导致编码错误的主要原因。通过对两种先天性囊肿病案回顾性分析,提高中肾管囊肿和副中肾管囊肿编码的正确率。Female mesonephric duct cyst and paramesonephric duct cyst are two common congenital cysts in female genital cysts,which are easily confused with acquired cysts of the female reproductive organs when coding.Both mesonephric duct cysts and paramesonephric duct cysts are classified based on the location of the disease,and another common error is the misplacement of the disease location.The ICD index is summarized based on the location of the renal duct route:Fallopian duct cysts are classified in Q50.4;Wide ligament cysts are classified as Q50.5;Cervical cysts are classified as Q51.6;Uterine cysts are classified as Q51.8;The vagina and hymen are classified in Q52.4.The main reasons for coding errors are insufficient clinical knowledge of coders,weak mastery of coding knowledge,lack of comprehensive reading of medical records,and excessive reliance on the national clinical dictionary library.This article provides a retrospective analysis of two types of congenital cyst cases,improve the accuracy of coding both of them.

关 键 词：中肾管囊肿 副中肾管囊肿 疾病编码 手术编码 案例 

分 类 号：R197.323[医药卫生—卫生事业管理]