ICD-9-CM-3中未特指编码误用问题探讨

目的 了解ICD-9-CM-3中具有未特指情况的手术与操作编码误用问题,分析错误原因,探讨对策.方法 总结201 1版ICD-9-CM-3中所有具有未特指情况的手术与操作编码,与北京协和医院现有手术和操作编码字典库进行比对,并在北京协和医院病案首页管理信息系统下对2012年住院首页信息中手术与操作的上述编码逐一进行检索,统计误用编码检索量,计算误用率.结果 参照最新版ICD-9-CM-3,共筛选出162个具有未特指情况的手术与操作编码,其中58个编码存在于我院字典库,逐一进行检索后发现的60.3％（35/58）的编码有病例支持,存在误用现象.总体上具有未特指情况编码误用率为15.5％,“NOS”编码误用率和“unspecified”编码误用率分别为17.0％和5.6％.结论 病案编目人员应谨慎使用具有未特指情况的手术与操作编码,建议添加编码信息质控程序提高编码准确性.

Discussion on the Misuse Problems of Unspecified Coding in ICD-9-CM-3

Objective To understand the problems of misuse coding for the unspecified operations and procedures in ICD-9-CM-3, analyze its reasons and discuss relevant countermeasures.Methods To summarize all the unspecified ceding for operations and procedures in ICD-9-CM-3 of 2011 version, and compared with the coding currently existing in dictionary database of Peking Union Medical College Hospital, then searched the coding above in 2012 respectively in the medical records home page management system of Peking Union Medical College Hospital, accounted the search numbers of misuse coding and calculated the misuse rate. Results Referring tO the latest version of ICD-9-CM-3, 162 unspecified coding of unspecified operations and procedures were screened out totally, in which 58 of 162 coding were searched out in the dictionary database of the hospital and 60.3% （ 35/58 ） of the coding had misuse situation and cases supporting. As a whole, the misuse rate of unspecified coding was 15.5%, the misuse rate of ＂NOS＂ code and ＂unspecified＂ coding were 17.0% and 5.6% respectively. Conclusion The coders of medical records should apply unspecified codes for operations and procedures cautiously, and quality control programs were suggested to increase the accuracy of coding.