胸腔镜中转开胸手术ICD-9-CM-3编码分析  

Analysis on ICD-9-CM-3 Coding of Thoracoscopic Surgery Conversion to Thoracotomy

作　　者：徐晓丽 刘媛[1] 汪刚 XXut Xiaoli;Liu Yuan;Wang Gang(Shanghai Chest Hospital Affiliated to Shanghai Jiao Tong University School of Medicine,Shanghai 200030,China;不详)

机构地区：[1]上海市胸科医院上海交通大学医学院附属胸科医院,上海市200030

出　　处：《中国病案》2025年第2期50-52,共3页Chinese Medical Record

摘　　要：目的 回顾性分析某院胸腔镜中转开胸手术ICD-9-CM-3编码情况,以提高编码的准确性。方法 通过病案统计管理系统检索某院2023年1月1日至2023年12月31日胸腔镜中转开胸手术病案143份,运用Excel整理汇总手术编码错误类型和原因。结果 143份病案均存在编码错误问题,138份胸腔镜检查错编成胸腔镜中转开胸探查术,5份胸腔镜手术错编成开放手术。其中7份主要手术编码错误,136份其他手术编码错误。错编原因包括编码员依赖字典库,编码员不熟悉编码规则,编码员缺乏临床知识,医师手术选择错误。结论 胸腔镜中转开胸手术情况复杂,编码错误率高。编码员应提升业务能力,加强对临床医师的培训,建立有效的质控体系,提高手术编码的准确性。Objectives The ICD-9-CM-3 coding of thoracoscopic surgery conversion thoracotomy in a hospital was retrospectively analyzed,so as to improve the accuracy of coding.Methods A total of 143 thoracoscopic surgery conversion exploratory thoracotomy medical records were retrieved from January 1st,2023 to December 31st,2023 through the medical records statistical management system.The types and causes of surgical coding errors were summarized by Excel.Results The coding errors were found in all the 143 cases.138 cases of thoracoscopy were misclassified as thoracoscopic surgery conversion to thoracotomy,and 5 cases of thoracoscopic surgery were misclassified as open surgery.Among them,7 cases were misclassified in the principal surgery and 136 cases in the secondary surgery.The causes of miscoding included the coders'reliance on dictionary,the coders'unfamiliarity with coding rules,the coders'lack of clinical knowledge,and the doctors'wrong surgical choices.Conclusions Thoracoscopic surgery conversion to thoracotomy was complicated,the rate of coding error was high.In order to improve the accuracy of surgical code,the coders should enhance their professional ability,strengthen the training of clinicians and establish an effective quality control system.

关 键 词：胸腔镜手术 中转开胸 手术编码 ICD-9-CM-3 

分 类 号：R197.323[医药卫生—卫生事业管理]