Case Analysis of Common Coding Errors in the C76 Category of Malignant Tumors
Objectives This study aims to analyze typical error cases of malignant tumors coded in the C76 category(malignant tumors of other and unclear locations)in a hospital in the past three years to improve the accuracy of malignant tumor coding.Methods A total of 53 medical records with the main diagnosis code of C76 category during the three years from January 1,2020 to December 31,2022 were retrieved from the inpatient medical record front page management system.Three coders and one associate chief physician of the Department of Pathology checked each case one by one according to the ICD tumor coding rules.Results A total of 49 cases had major diagnostic coding errors using the C76 category,with an error rate of 92.45％.The corrections were classified into the following categories:There were 12 cases each of connective tissue and soft tissue malignant tumors,cutaneous melanoma and other malignant skin tumors,and oral malignant tumors,and the error proportions were all 24.49％;There were 4 cases each of malignant tumors of female reproductive organs,secondary malignant tumors of lymph nodes and other parts,and tumors of connective tissue and other soft tissues whose dynamics were undetermined or unknown,and the error ratio was 8.16％;There was 1 case of B-cell lymphoma,and the error rate was 2.04％.Conclusions The main diagnostic errors coded in the top 3 digits of the C76 category occur in connective tissue and soft tissue malignant tumors,skin melanoma and other malignant skin tumors,oral malignant tumors,etc.Most of the errors are made by coders with less than 5 years of coding experience.Some clinicians do not write standardized tumor diagnoses,coders lack knowledge of pathology and anatomy,are not familiar with tumor coding rules,and do not read surgical records carefully,which are the main reasons for incorrect coding in the C76 category.Strengthening training and quality control in tumor diagnosis writing and disease coding is the key to reducing coding error rates.
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