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肩关节脱位手术编码浅析

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肩关节脱位主要包括急性脱位、陈旧性脱位和复发性脱位.肩关节脱位的手术方式主要有手法复位、切开复位和关节修补术.在对肩关节脱位手术进行编码时,应注意主导词和修饰词的选择,编码员要按照工具书中的编码规则结合临床实际进行编码,要根据手术记录明确手术术式.肩关节急性脱位和陈旧性脱位做手法复位时编码79.71肩脱位闭合性复位术,伴有肱骨骨折做骨折切开复位内固定时编码79.31肱骨骨折开放性复位术伴内固定;肩关节复发性脱位做修补术时编码81.82复发性肩脱位的修补术.案例分析编码人员在编码过程中可能存在的问题,让编码员意识到除了掌握国际疾病的分类知识以外,还需学习相关医学知识,及时与临床医师沟通,更重要的是要擅于使用ICD-9-CM-3编码工具书,正确选择主导词和修饰词,提高国际疾病分类专业技能,以提高编码的准确率.
Coding Analysis of Shoulder Dislocation Surgery
Shoulder dislocation mainly includes acute dislocation,old dislocation and recurrent dislocation.The main surgical methods of shoulder dislocation are manual reduction,open reduction and joint repair.When encoding shoulder dislocation surgery,attention should be paid to the selection of leading words and modifiers.Coders should encode according to the coding rules in reference books combined with clinical practice,and the surgical procedure should be defined according to surgical records.Manual reduction for acute dislocation and old dislocation of shoulder joint codes 79.71 closed reduction for shoulder dislocation and open reduction for internal fixation for humeral fracture codes 79.3 1 Open reduction for humeral fracture with internal fixation;Repair of recurrent shoulder dislocation Code 81.82 Repair of recurrent shoulder dislocation The case of shoulder dislocation surgery was analyzed to analyze the problems that coders might have in the coding process,so that coders could realize that in addition to mastering the knowledge of international classification of diseases,they should also learn relevant medical knowledge,communicate with clinicians in a timely manner,and more importantly,they should be good at using ICD-9-CM-3 coding reference books and correctly select leading words and modifiers.Improve ICD expertise to improve coding accuracy.

Dislocation of the shoulder jointICD-9-CM-3Code analysis

宋翠兰、马志晖

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大连医科大学附属第二医院,辽宁省,大连市,116027

肩关节脱位 ICD-9-CM-3 编码分析

2024

中国病案
中国医院协会

中国病案

CSTPCD
影响因子:1.197
ISSN:1672-2566
年,卷(期):2024.25(6)