多原发恶性肿瘤ICD-10编码探讨
Discussion on multiple primary malignancy ICD-10 coding
胡颖辉 1孔德莹 1左煌 1闫学丽1
作者信息
- 1. 西安交通大学第一附属医院 陕西西安 710061
- 折叠
摘要
目的 通过分析某三甲医院多原发恶性肿瘤的编码质量,找出存在的问题,提高多原发恶性肿瘤的编码准确率.方法 收集某三甲医院2021 年6 月1 日—2023 年6 月30 日出院诊断含有ICD-10 编码C97 的病案393 份,通过详细阅读病案,分析多原发恶性肿瘤C97 编码容易出错的原因.结果 393 份病案中,34 份存在C97 编码错误,其中将交搭跨越恶性肿瘤错误编码至多原发恶性肿瘤11 份,将同一器官系统中不相邻部位病理类型相同的恶性肿瘤错误编码至多原发恶性肿瘤9 份,将远处转移或局部侵犯错误编码至多原发恶性肿瘤7 份,将良性肿瘤当成恶性肿瘤导致编码错误4 份,恶性肿瘤疑诊当成确诊编码3 份.结论 要提高C97 编码的质量与效率,编码员需明确多原发恶性肿瘤的定义,认真完整地阅读病案资料,明确肿瘤的部位和病理类型,加强与临床医师的沟通.
Abstract
Objective To analyze the coding quality of multiple primary malignant tumors in a tertiary hospital,identify existing problems,and improve the accuracy of coding for multiple primary malignant tumors.Methods We collected 393 medi-cal records from a tertiary hospital from June 1,2021,to June 30,2023,with ICD-10 code C97 for the discharge diagnosis.By carefully reading the medical records,we analyzed the reasons for coding errors in multiple primary malignant tumors with code C97.Results Among the 393 medical records,there were 34 cases with coding errors in C97,including 11 cases where meta-static malignant tumors were erroneously coded as multiple primary malignant tumors,9 cases where malignant tumors of the same organ system with non-adjacent sites and the same histological type were erroneously coded as multiple primary malignant tumors,7 cases where distant metastasis or local invasion was erroneously coded as multiple primary malignant tumors,4 cases where be-nign tumors were mistakenly coded as malignant tumors,and 3 cases where suspected malignant tumors were coded as confirmed cases.Conclusion To improve the quality and efficiency of C97 coding,coders need to have a clear understanding of the defini-tion of multiple primary malignant tumors,read the medical records carefully and completely,determine the location and histolog-ical type of the tumors accurately,and strengthen communication with clinical physicians.
关键词
多原发恶性肿瘤/病案质控/ICD-10/疾病编码Key words
Multiple primary malignant tumors/Medical record quality control/ICD-10/Disease coding引用本文复制引用
出版年
2024
国家科技期刊平台
NSTL
万方数据