原发灶不明恶性肿瘤的ICD-10编码质量分析  

Quality Analysis of ICD-10 Coding for Malignant Tumors of Unknown Primary Focus

作　　者：胡颖辉 闫学丽 孔德莹 汤瑞祥 Hu Yinghui;Yan Xueli;Kong Deying;Tang Ruixiang(The First Affiliated Hospital of Xi'an Jiaotong University,Xi'an 710000,Shanxi Province,China;不详)

机构地区：[1]西安交通大学第一附属医院医疗信息管理办公室,陕西省西安市710000 [2]西安交通大学第一附属医院肿瘤外科,陕西省西安市710000

出　　处：《中国病案》2025年第2期52-55,共4页Chinese Medical Record

基　　金：陕西省自然科学基础研究计划(S2023-JC-QN-1422)。

摘　　要：目的 通过分析某三甲医院原发灶不明恶性肿瘤的编码质量,找出存在的问题,提高编码准确率。方法 收集某三甲医院2013年1月1日-2023年12月31日出院诊断中含有“原发灶不明”“原发不明”“原发部位不明”“原发部位不明确”“不明原发灶”“原发灶不明肿瘤”“原发部位不明确恶性肿瘤”“不明原发灶肿瘤”“原发部位未知”等字段,且病理报告明确为转移性恶性肿瘤的病例556例。由5名高年资编码员和1名临床专家、1名病理专家依据ICD-10肿瘤编码原则逐一核查病案编码准确性,统计错误编码的数量和类型,并使用构成比来统计编码错误的情况。结果 556份病案中,301份存在编码错误,占总数的54.1%。按照肿瘤形态学分类的结果为:常规病理类型病例492例,其中错误编码251例,占比51.0%。病理类型为结缔组织来源恶性肿瘤36例,其中编码错误29例,占比80.5%;病理类型为恶性黑色素瘤26例,其中编码错误19例,占比73.1%;病理类型为骨或软骨来源恶性肿瘤2例,其中编码错误2例,占比100.0%;结论 原发灶不明恶性肿瘤编码错误的主要原因在于编码员过度依赖电脑字典库、对原发灶不明恶性肿瘤编码原则不熟悉、缺少临床知识。编码员需建立查阅工具书的良好习惯,增加临床知识储备,加强与临床医生的联系,从而提高编码准确性。Objectives By analyzing the ICD-10 coding for malignant tumors of unknown primary focus in a Three A and Tertiary Hospital,to identify the problems and improve the coding accuracy.Methods A collection of physician-end diagnoses from January 1st,2013,to December 31st,2023,originating from a Three A and Tertiary Hospital was reviewed.The review focused on cases containing terms such as"unknown primary focus,""malignant tumor of unknown primary site,"and others.A total of 556 cases underwent individual verification by five senior coders,a clinical expert,and a pathologist,in accordance with ICD tumor coding guidelines.Firstly,count the number and type of coding errors.Then,use the composition ratio to analyze the distribution of these errors.Results Of the 556 cases,301 had coding errors,accounting for 54.1%of the total.According to the classification results of tumor morphology,there were 492 cases of conventional pathological types,among which 251 cases were miscoded,accounting for 51.0%.The pathological type was connective tissue derived malignant tumor in 36 cases,of which 29 cases(80.5%)were coded incorrectly.The pathological type was malignant melanoma in 26 cases,among which 19 cases were coding errors,accounting for 73.1%.The pathological type was malignant tumor of bone or cartilage origin in 2 cases,of which 2 cases were coding error,accounting for 100.0%.Conclusions The main reasons for coding errors of malignant tumors of unknown primary focus were over-reliance on computer dictionary,unfamiliarity with coding principles of unknown primary malignancies and lack of clinical knowledge.Coders needed to establish a good habit of consulting reference books,increase the clinical knowledge reserve,strengthen the contact with clinicians,so as to improve the accuracy of coding.

关 键 词：原发灶不明恶性肿瘤 肿瘤形态学 ICD-10 疾病编码 

分 类 号：R197.323[医药卫生—卫生事业管理]