选择性阴茎背神经离断术手术编码的探讨

目的 探讨选择性阴茎背神经离断术手术编码.方法 采用ICD-10以F52.4（早泄）为检索词,在病案统计管理系统检索出2009-2013年病例277份,其中操作210例手术,以ICD-9-CM-3 2008版为工具书,回顾性分析选择性阴茎背神经离断术手术编码的质量.结果 发现错误编码64.2阴茎病损的局部切除术或破坏术124例,误编64.4阴茎修补术和整形术51例;03.1脊髓内神经根切断或脊神经根切断术35例,错误率16.66％,正确编码应为04.03其他颅的和周围神经切断术或压轧术,延拓细化尾码04.0301.结论 编码员对手术范围,术式以及解剖部位的错误判断导致选择性阴茎背神经离断术编码错误.手术确定阴茎背神经的解剖位置是编码的关键,编码员必须认真阅读手术记录,熟练掌握解剖知识,提高医学知识和国际疾病分类专业技能,才能确保编码准确.

Discussion of the ICD-9-CM-3 Coding of Selective Penile Dorsal Nerve Amputation Operation

Objective To discuss the code of selective penile dorsal nerve amputation operation. Method We searched 277 cases （210 cases of surgical operations） during 2009 and 2013 with 1CD-10 F52.4 （premature ejaculation） as a search term by medical record management system and retrospectively analyzed the quality of surgical coding of selective dorsal penile nerve amputation operation by ICD-9-CM-3 2008. Result The amount of error code 64. 2 of penile lesions local excision or destruction is 124. The amount of error code 64. 4 of penis repair and orthopedic surgery is 51. The amount of error code 03.1 of spinal cord and nerve roots cut off is 35. The error rate is 16. 66%. The correct code is 04. 03 other cranial and peripheral nerve transection or nip and refinement extension suffix 04. 0301. Conclusion Coder misjudgment of the extent of surgery, surgical anatomy result in coding errors. The anatomical location of dorsal penile nerve is the key. so coders must carefully read the surgical records, proficiency anatomical knowledge, improve medical knowledge and expertise International Classification of Diseases, ensure accurate coding.