首页|腹腔镜微创手术名称编码分析

腹腔镜微创手术名称编码分析

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在国内外临床实践中,腹腔镜常用于腹腔各脏器手术:腹腔镜直肠癌根治术及腹股沟疝修补术等.腹腔镜直肠癌根治术主要是指经腹腔镜微创手术切除直肠肿瘤病灶、全直肠系膜、保留盆腔自主神经、区域淋巴结清扫的所有微创腹腔镜手术术式.这些不同的手术方式可由一种手术类型,如Dixon术经腹腔镜微创手术构成,也可以由多个不同的腹腔镜微创手术名称组合而成,其中,多包含了"经括约肌间切除术腹腔镜微创手术"及"经肛全直肠系膜切除术腹腔镜微创手术"等手术类型.但在实际的编码过程中,很多编码员往往会将常见腹腔镜微创手术的具体名称笼统地填写为48.6900x002腹腔镜下直肠根治术,而并未结合腹腔镜手术某种具体的微创手术具体实施方式,正确填写与之相对应的腹腔镜微创手术编码.腹腔镜疝修补术的手术编码时要注意是否单、双侧;直、斜疝;是否补片修补.基于此,在腹腔镜微创手术名称及编码工作开展实践中,临床医生应多与编码员交流沟通,相互学习和补充专业知识,分析病案首页腹腔镜微创手术名称及编码填写存在的主要问题,从而有针对性地根据国际疾病分类(ICD)编码规则,进行病案首页腹腔镜微创手术名称及编码的正确填写.与此同时,要加强手术名称编码专业知识与技能培训,让临床医师、编码员熟悉和详细了解每种腹腔镜微创手术名称及其ICD编码对应关系,进而有效规范腹腔镜微创手术名称填写行为,并将其手术名称填写缺陷、编码问题与医院绩效考核相挂钩,由此促进编码员和临床医师有效提高临床常见腹腔镜微创手术ICD编码正确率.
Analysis of Name Coding for Laparoscopic Minimally Invasive Surgery
In clinical practice both domestically and internationally,laparoscopic minimally invasive surgery is commonly seen as radical resection of rectal cancer.It mainly refers to all minimally invasive laparoscopic surgical procedures that involve laparoscopic minimally invasive surgery to remove the entire mesorectum,preserve the pelvic autonomic nervous system,remove tumor lesions,and perform regional lymph node dissection.These different surgical methods can be composed of one surgical type,such as Dixon's laparoscopic minimally invasive surgery,or a combination of multiple different laparoscopic minimally invasive surgical names,including"ISR laparoscopic minimally invasive surgery"and"taT-ME laparoscopic minimally invasive surgery".However,in the actual clinical diagnosis and treatment process,many clinical physicians often fill in the specific name of common laparoscopic minimally invasive surgery as laparoscopic surgery in a vague manner,without considering the specific implementation method of laparoscopic surgery for patients and correctly filling in the corresponding laparoscopic minimally invasive surgery name.Based on this,in the practice of laparoscopic minimally invasive surgery names and coding,clinical doctors should communicate more with coders,learn from each other and supplement professional knowledge,analyze the main problems in filling in the name of laparoscopic minimally invasive surgery on the front page of each patient's clinical case medical record,and accordingly,according to the ICD coding rules,fill in the name of laparoscopic minimally invasive surgery on the front page of clinical cases.At the same time,it is necessary to strengthen the professional knowledge and skill training of surgical name coding,so that clinical doctors and coders are familiar with and have a detailed understanding of each type of laparoscopic minimally invasive surgery name and its corresponding ICD code relationship.This can effectively regulate the behavior of filling in laparoscopic minimally invasive surgery names,and link their surgical name filling defects and coding problems with hospital performance evaluation,thereby promoting coding.Staffand clinical physicians effectively improve the accuracy of ICD coding for common laparoscopic minimally invasive surgeries in clinical practice.

laparoscopythe name of minimally invasive surgeryencoding analysisinternational classification of diseases

黄剑屹、陈济兰

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赣州市南康区第一人民医院病案室(江西 赣州 341400)

于都县第二人民医院病案室(江西 赣州 342323)

腹腔镜 微创手术名称 编码分析 国际疾病分类

2024

中国医疗器械信息
中国医疗器械行业协会

中国医疗器械信息

影响因子:0.375
ISSN:1006-6586
年,卷(期):2024.30(19)