158例神经胶质瘤编码分析

目的分析某三甲医院神经胶质瘤错误编码,提高神经胶质瘤编码准确性。方法以"M938-M948"为检索区间,筛选某三甲医院2019年1月1日-2020年5月31日出院病案,按照ICD-10编码原则及相关临床病理知识对检索出的病案进行逐个核查。用excel软件统计错误编码、错误类型以及相关临床病理内容。结果全院符合条件158例,本院区142例,错误60例,占本院错误比42.25%,东院区16例,错误13例,占东院区错误比81.25%。错误类型中单纯形态学编码错误最高,其中胶质母细胞瘤错误编码最多占91.67%,单纯部位编码错误和部位编码与形态学编码均错误占比一样。部位编码错误中亚目.9的使用占50.00%,交搭跨越未正确使用占37.50%。结论神经胶质瘤编码错误率高,主因编码员缺乏临床知识;对国际疾病分类知识理解不够深入;编码员间缺乏沟通。科室通过设立专职编码质控人员;邀请临床医师讲解;加强院区间沟通,来提高全院编码质量。

Coding Analysis of 158 Cases of Glioma

Objective Improve the accuracy of glioma coding by analyzing the wrong coding of glioma in a top three hospital.Method Retrieving the medical records of a top three hospital from January 1,2019 to May 31,2020 on the condition of"M938-M948",according to the ICD-10 coding principle and related clinical pathology knowledge,the retrieved medical records are checked one by one.The error coding,error type and its related clinical pathology were statistically analyzed with excel software.Results There are 158 eligible cases in the whole hospital,among the 142 cases in this hospital,60 were errors,accounting for 42.25%of the errors in this hospital.There were 16 cases in the Eastern Hospital,13 of which were errors,accounting for 81.25%of the errors in the Eastern Hospital.Among the types of errors,simple morphological coding errors were the highest,among which glioblastoma coding errors accounted for 91.67%at most,the proportion of simple part coding errors is the same as that of part coding and morphological coding.In the part coding errors,the use of suborder.9 accounted for 50.00%,and the incorrect use of overlapping spans accounted for 37.50%.Conclusions The coding error rate of glioma was very high.Reasons for incorrect coding include lacking of relevant clinical knowledge of coders,lacking of in-depth understanding of international disease classification knowledge,and lacking of communication between coders.The department can set up a full-time coding inspector,invite clinicians to give professional knowledge,Strengthen the communication between coders to ensure the accuracy of coding.