泌尿生殖系统疾病ICD-10编码体会

泌尿生殖系统疾病属常见病,本章的分类有以下特点:①有些疾病是以病因为分类轴心。②有些临床诊断术语相同,由于强调病因而不分类于本章。③本章结构有些是以性别为分类轴心。④肿瘤性疾病引起的肾小球疾病,要用星剑号编码,肿瘤部位码为主要编码,而肿瘤形态学的编码就不一定要写出。⑤有些诊断术语需了解其含义,才能正确选择主导词查找编码。在选择编码时如果忽略了本章的分类特点及分类原则,将易造成编码的失误,编码员除应具备较广的医学知识外,掌握每章的编码特点及分类原则十分重要。     

原发性鼻腔脑膜瘤ICD-10与ICD-11编码对比分析

目的 探讨ICD-10与ICD-11疾病编码查询和构成的不同,为当前ICD-10正确编码提供更好地理解和思路参考。方法 以原发性鼻腔脑膜瘤为研究对象,从章节结构、编码组成、部位编码、形态学编码和其他扩展编码等方面详细对比分析ICD-10和ICD-11编码。结果 查找原发性鼻腔脑膜瘤ICD-10疾病编码,核对卷一发现部位编码分类于脑部肿瘤,需修正编码方可使用。ICD-11用一个组合的簇编码来详细表示复杂的肿瘤编码,ICD-11的形态学分类更符合临床实际分类,ICD-11扩展码能反应严重程度、侧位和肿瘤分期。结论 ICD-11有利于更精确地统计医疗信息,应尽早应用。     

内生软骨瘤编码探讨

目的 探讨内生软骨瘤的疾病分类编码,提高其编码准确率。方法 通过内生软骨瘤的病因、发病机制、解剖部位、临床表现和病理,结合ICD-10分类原则,分别以“软骨瘤”、“软骨瘤病”、“内生软骨瘤病”作为主导词查找编码。结果 内生软骨瘤病的疾病编码应以良性肿瘤为主,具有发育障碍特征的应辅以Q78.4加以区分说明。单发性内生软骨瘤的主要编码应为D16.-M9220/0,多发性内生软骨瘤病的主要编码应为D48.0 M9220/1,并附加Q78.4。结论 内生软骨瘤是常见的软骨源性的良性骨肿瘤,合并肢体畸形称为多发性内生软骨瘤病,合并皮肤、软组织和内脏血管瘤者称为Maffucci′s综合征,均为发育障碍性疾病综合征,因此,内生软骨瘤的编码应以肿瘤为主,具有发育障碍特征的应辅以Q78.4加以区分说明。     

相同肿瘤形态学术语编码的应用辨析

在ICD-9的疾病分类中，肿瘤的分类比较复杂。因此，限定肿瘤分类的惯例、术语、符号也比较多。通常只要按照查找肿瘤编码的操作步骤，就可以正确选择到肿瘤形态学编码和部位编码。但是在实际工作中，往往会遇到一些相同肿瘤形态学术语、不同编码的分类情况，为编码确定工作带来了一定的困难，直接影响了ICD-9分类的准确性。解决的方法，就是在实际应用中认真地加以辨析。下面试举几例：     

谈肿瘤的形态学编码-M编码

目的探讨肿瘤的形态学编码-M编码。方法用一些典型的例子，对肿瘤形态学编码的基本原则及形态学编码与部位编码间的相互关系进行阐述。结果肿瘤的形态学编码是说明肿瘤的起源组织及良、恶性情况的。形态学编码与部位编码之间的相互联系要注意5方面的情形：一一对应的情形，不对应的情形，肿瘤的组织学类型多发性的情形，淋巴、造血和有关组织的肿瘤的情形及1个形态学编码包含具有2个编码的定性形容词时的情形。结论肿瘤的形态学编码与肿瘤的部位编码共同构成完整的肿瘤编码，与肿瘤的部位编码相互影响，密切相关。对不同病理学类型肿瘤的组织发生、形态学特征全面地认识和理解，是肿瘤正确分类的关键。     

ICD一10编码在先天畸形疾病分类中的扩展研究

目的解决ICD一10疾病分类中先天畸形未收录的疾病名称和临床诊断无对应编码的问题。方法汇总天津市儿童医院1998年1月～2008年1月诊治的所有先天畸形疾病诊断和临床需求1043条,按照ICD一10疾病分类思想、分类原则和编码查找方法,应用扩展码编码具体操作程序确定对应编码。结果研究解决的编码分为3种：可确定编码、新增扩展码、补充扩展码,建立了先天畸形疾病编码和扩展编码字典库。结论完善先天畸形疾病分类中医学信息代码的规范模式,可减少误码率,规范临床诊断,有利于病历档案信息资源的开发与利用。     

结肠息肉诊断在不同病例中的疾病编码

根据不同的病理结果，按照国际疾病分类原则，通过个案分析，探讨结肠息肉 ICD-10编码。临床诊断相同都是结肠息肉，但其病理检验结果不同，结肠息肉的疾病分类就不同。编码人员对结肠息肉疾病分类时，必须根据病理检验诊断结果的组织形态，结合分类原则，严格执行正规查找方法，才能正确编码，提高编码准确率。     

关于陷凹（窝）的ICD-9-CM3手术分类

对工作实践中遇到的陷凹（窝）ICD-9-CM3编码问题,结合手术分类原则,提出了先明确＂陷凹（窝）＂的解剖部位以及编码所归的解剖部位,如果索引中查找不到确切的编码解剖部位,可以参照ICD-10肿瘤表所列出的部位,最后决定编码.     

消化系统神经内分泌肿瘤ICD-O形态学编码对DIP分组的影响北大核心CSCD

目的了解消化系统神经内分泌肿瘤ICD-O形态学编码对DIP分组的影响,以提高编码质量。为医保按病种分值付费提供参考依据。方法应用数据挖掘语言SQL从某院的病案统计管理系统中查询形态码为神经内分泌肿瘤的45份病历,根据WHO(2019)消化系统肿瘤分类确定消化系统神经内分泌肿瘤的ICD-O形态学编码,对比分析编码员疾病编码与经ICD-O形态学编码修正疾病编码的每一份病历入DIP组别的差异,DIP差值之间的差异采用配对秩和检验。结果45份消化系统神经内分泌肿瘤疾病编码分类到了D37(动态未定或动态未知的肿瘤)、D12/D13(良性肿瘤)和D01(原位肿瘤)中,均需根据其ICD-O形态学编码M8240/3和M8249/3(/3恶性,原发部位),编码到相应原发部位的恶性肿瘤(C00-C75)。编码员疾病编码与经ICD-O形态学编码修正疾病编码的DIP分组之间的差异显著,不同疾病编码DIP组病种分值差异有统计学意义(Z=-5.967,P<0.05),最大病种分值相差2360分。结论随着医疗支付改革的深入,医疗机构要重视疾病编码的内涵质控,消化系统神经内分泌肿瘤疾病性质对DIP分组有显著影响。     

应用ICD-9-CM-3骨科手术编码的探讨

我院是一所以骨伤科为主的中医院 ,其中骨科病床占全院病床总数的 70 %。为了适应医院临床、教学、科研的需要 ,提高病案工作质量和工作效率 ,按ＩＣＤ 9 ＣＭ 3的原则 ,我们对一些骨科手术分类编码进行了增码、扩码工作。通过实践我们认为切实可行。在进行骨科手术编码时见到 ,ＩＣＤ 9 ＣＭ 3中有关“骨折和脱位的复位术”一节中 ,一些骨科手术编码不够详细 ,有些不同的手术方式 ,不同部位的手术需要放在同一编码中。这样 ,在临床查找手术资料时 ,很难直接找出所需的资料 ,而且找出的资料不准确、不完整。病案工作人员的工作量加大 ,临床…     

神经鞘瘤的疾病与手术编码案例分析

神经鞘瘤是发生于周围神经和中枢神经的良性肿瘤,属于神经肿瘤。由于编码人员的临床医学知识不足,对神经鞘瘤的疾病类型和手术方式不够熟悉,过于依赖计算机编码,以及编码制度中缺乏编码复核质控等原因,导致编码工作中常会发生将神经鞘瘤错误编码为疾病发生部位的良性肿瘤。本文介绍了神经鞘瘤的临床特征及其疾病和手术编码,同时通过3例神经鞘瘤典型病例的回顾性研究,分析编码错误的原因,总结了神经鞘瘤编码思路。医疗机构应当重视编码工作,不断提升编码员的业务能力和责任心,并通过设立专科编码员,建立病案首页的编码复核等机制来提高疾病及手术编码的正确率。     

建立有效学习机制 提升病案编码水平

目的提升病案编码员对疾病和手术的理性与感性认识,提高病案编码水平。方法通过建立有效学习机制,特别是后期参加临床科室的业务学习,观看编码中遇到的概念模糊和抽象的手术。结果编码员对疾病及手术有了较为透彻的理解并融会贯通,病案编码的准确性及处理疑难编码的能力大幅提高。结论建立有效学习机制,特别是参加临床科室的业务学习,能明显提高病案编码员的编码水平。     

The reliability of cause-of-death coding in The Netherlands

Cause-of-death statistics are a major source of information for epidemiological research or policy decisions. Information on the reliability of these statistics is important for interpreting trends in time or differences between populations. Variations in coding the underlying cause of death could hinder the attribution of observed differences to determinants of health. Therefore we studied the reliability of cause-of-death statistics in the Netherlands. We performed a double coding study. Death certificates from the month of May 2005 were coded again in 2007. Each death certificate was coded manually by four coders. Reliability was measured by calculating agreement between coders (intercoder agreement) and by calculating the consistency of each individual coder in time (intracoder agreement). Our analysis covered an amount of 10,833 death certificates. The intercoder agreement of four coders on the underlying cause of death was 78%. In 2.2% of the cases coders agreed on a change of the code assigned in 2005. The (mean) intracoder agreement of four coders was 89%. Agreement was associated with the specificity of the ICD-10 code (chapter, three digits, four digits), the age of the deceased, the number of coders and the number of diseases reported on the death certificate. The reliability of cause-of-death statistics turned out to be high (>90%) for major causes of death such as cancers and acute myocardial infarction. For chronic diseases, such as diabetes and renal insufficiency, reliability was low (<70%). The reliability of cause-of-death statistics varies by ICD-10 code/chapter. A statistical office should provide coders with (additional) rules for coding diseases with a low reliability and evaluate these rules regularly. Users of cause-of-death statistics should exercise caution when interpreting causes of death with a low reliability. Studies of reliability should take into account the number of coders involved and the number of codes on a death certificate.     

浅谈艾森门格综合征的编码体会

我国实行国际疾病分类(ICD-10)非常重要:①便于国内与国际交流;②医疗、科研与教学病案资料的检索;③医院管理信息的提取;④医院等级评审;⑤临床路径应用;⑥临床重点学科申报;⑦医保管理、医疗付款等方面。所以编码人员必须根据临床诊断结合ICD-10编码原则,正确编码。笔者从ICD-10第二版索引中发现,以艾森门格尔命名的疾病编码有两个,分别分类到第九章循环系统疾病与第十七章先天性畸形、变形和染色体异常两章。两者的区别与编码选择使编码者感到困惑,因此,查阅了一些有关资料,对此疾病的编码进行探讨。     

Coding on the home front

Recently, a group of coders participated in a survey about their day-to-day experiences as remote, or at-home coders. The survey asked a series of questions related to the positives and negatives of coding at home versus coding in the more traditional office setting. Below is a summary of the survey findings.     

颈椎间盘切除+前路脊柱植骨融合术编码的探讨

目的探讨颈椎间盘切除+前路脊柱植骨融合术的ICD编码。方法以ICD-9-CM-32008版为工具书,仔细阅读病案,根据手术分类编码原则进行准确编码。结果手术操作术式和路径及所用器械或材料不同,手术操作分类的编码亦不同。结论编码员必须认真阅读病案及手术记录,提高医学知识和国际疾病分类专业技能,这是准确进行编码的关键。     

Accuracy of cause-of-death coding in Taiwan: types of miscoding and effects on mortality statistics

BACKGROUND: The objectives of this study were to assess the accuracy of cause-of-death coding, determine the extent to which coders follow the selection rules of coding set out in the International Classification of Diseases, 9th Revision (ICD-9), and the effects of miscoding on mortality statistics in Taiwan. METHOD: A systematic sample of 5621 death certificates was reviewed. The underlying cause of death (UCD) selected by the reviewer for each death certificate was compared with that selected by the original coder. The UCD was selected according to ACME (Automated Classification of Medical Entities) Decision Tables. RESULTS: The overall agreement rates between the reviewer and coders according to the three-digit and two-digit categories of ICD-9 were 80.9% and 83.9%, respectively. Good agreement was found for malignant neoplasms (kappa = 0.94) and injuries and poisoning (kappa = 0.97), but there was poor agreement for nephrotic diseases (kappa = 0.74), hypertension-related diseases (kappa = 0.74), and cerebral infarction (kappa = 0.77). Reasons for disagreements included disagreement in nomenclature (42.8%), inappropriate judgement of causal relationships (41.5%), and incorrect interpretation of Selection Rule 3 and Modification Rules (15.7%). CONCLUSION: This study showed various levels of agreement for different diseases between the reviewer and the original coders in selection of the UCD. Owing to the 'compensatory effect of errors', the national mortality statistics were not affected significantly. The national administration should undertake routine internal studies to control the quality of UCD coding practices.