Coding Analysis of Relevant Operations in Endoscopic Retrograde Cholangiopancreatography
Objectives To investigate the coding situation of endoscopic retrograde cholangiopancreatography(ERCP)and its therapeutic operation,analyze the problems and propose improvement measures to improve the coding quality.Methods A total of 409 inpatient cases of endoscopic retrograde cholangiopancreatography(ERCP)and its treatment procedures discharged from a hospital from January 1st,2021 to December 31st,2022 were reviewed retrospectively,and the coding defects of the operation procedures were counted,and the causes of coding defects were classified and summarized.Results Among the 409 medical records,there were 69 problematic medical records,and the error rate was 16.87%.There were 93 wrong entries in the 69 problematic medical records,11 of which had errors in the coding of major surgical procedures and other surgical procedures,and 32 of them had errors in the coding of major surgical procedures,accounting for 34.41%of the total number of wrong entries.There were 61 coding errors in other surgical procedures,accounting for 65.59%of the total number of wrong entries.Conclusions Through the cause analysis,the coder's failure to strictly abide by the coding rules,insufficient clinical knowledge,insufficient communication with the clinic,and irregular clinical writing were the main reasons for coding errors in endoscopic retrograde cholangiopancreatography and its treatment operations.Coders needed to strengthen their own learning,increase clinical knowledge reserves,use ICD-9-CM-3 reference books to find and check codes,actively communicate with clinical practices,and improve the coding quality of ERCP and its treatment operations.
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