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肝恶性肿瘤介入治疗分类与ICD编码案例分析

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肝恶性肿瘤介入治疗主要涉及心血管系统手术、消化系统手术和一些诊断性、治疗性操作,参照《国际疾病分类第九版手术与操作ICD-9-CM-3》(2011 修订版)一书,相关的病案首页手术编码操作集中在第九章心血管系统手术、第十一章消化系统手术及第十八章各种诊断性和治疗性操作相关章节。通过病案编码员阅读手术记录,提取手术步骤,进而查找到正确手术操作编码及其排序,已成为目前介入手术病案首页填写的难点。按照目前肝恶性肿瘤介入治疗的分类,主要以"动脉造影术""栓塞""灌注""植入""破坏"及"消融"为主导词进行查找。
Classification of interventional therapy and ICD coding of hepatic malignant tumors:a case study
Interventional therapy for hepatic malignant tumours primarily includes cardiovascular system surgery,diges-tive system surgery,and various diagnostic and therapeutic procedures.Referring to the"International Classification of Diseases,Ninth Edition,Clinical Modification,ICD-9-CM-3"(2011 revision),the relevant surgical procedure codes on the front page of the case are contained mainly in the 9th chapter for cardiovascular system surgery,the 11th chapter for digestive system surgery,and the 18th chapter for various diagnostic and therapeutic procedures and other related chapters on diagnostic and therapeutic procedures.It has become a challenge for the history coders to complete the first page of interventional surgery cases by reviewing the surgery records,extracting the surgical steps,and then identifying the appropriate surgery codes and their sequencing.Accord-ing to the current classification of interventional therapy for hepatic malignant tumors,it is suggested to conduct the search and re-trieval using the keywords like"arteriography""embolization""perfusion""implantation""destruction"and"ablation".

Hepatic malignant tumorInterventional therapyICD-9-CM-3Surgical procedure coding

李媛、王洪涛、张炜浩、李良

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天津市肿瘤医院天津医科大学肿瘤医院//国家恶性肿瘤临床医学研究中心//天津市恶性肿瘤临床医学研究中心//天津市肿瘤防治重点实验室 天津 300060

肝恶性肿瘤 介入治疗 ICD-9-CM-3 手术操作编码

天津市医学重点学科(专科)建设项目

TJYXZDXK-012A

2024

现代医院
广东省医院协会

现代医院

影响因子:1.332
ISSN:1671-332X
年,卷(期):2024.24(2)
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