Objectives This study aims to analyze the causes of coding errors in diseases and surgeries involving space-occupying masses in the sella turcica area,explores the correct coding for such diseases and surgeries,and improves the accuracy of coding.Methods A total of 285 medical records were retrieved from the front page of discharge medical records of a tertiary hospital from January 1,2020 to August 31,2023,which showed an outpatient diagnosis of sellar space-occupying lesions and corresponding surgery during hospitalization.Coding quality control and problem analysis were conducted on these medical records.Results 250 cases were neoplastic diseases,and 35 cases were non-neoplastic diseases.The overall disease diagnosis coding accuracy rate was 91.22％,and the surgery coding accuracy rate was 81.75％.The coding error rate for surgeries for non-neoplastic diseases was the highest,at 42.86％.The causes of the errors were related to the coders'lack of relevant anatomical knowledge,confusion about the surgical resection site,and failure to read the surgical records carefully.Conclusions The surgical coding error rate of occupied lesions in the sella region is high.Coders need to strengthen the learning of relevant clinical knowledge,read medical records carefully,and continuously improve the quality of coding.
关键词
蝶鞍区占位疾病/疾病编码/手术编码/编码质量
Key words
Occupied lesions in sella region/Disease code/Operation code/Coding quality
维普
万方数据