腰椎滑脱ICD-10疑难编码的研究

THE RESEARCH OF DIFFICULT CODING IN SPONDYLOLISTHESIS ICD-10

目的探讨腰椎滑脱ICD-10编码与病因及损伤因素之间的关系。方法结合影像学诊断,对38份腰椎滑脱病案的ICD-10编码进行回顾性分析研究。结果其中15份病案疾病诊断ICD-10编码错误,33份病案的ICD-10编码不全。结论腰椎滑脱ICD-10编码必须结合影像学诊断,认真阅读病案,掌握疾病分类轴心是提高ICD-10编码质量的保证。

Objective Discuss the relations among the spondylolisthesis coding, disease cause and damage factors. Methods Linking the image diagnosis, retrospectively review 38 cases of lumbar spondylollsthesis, analyzes the ICD - 10 coding in their medical record. Results Among them, there are 15 cases with error ICD - 10 code of diagnosis, 33 cases with incomplete ICD - 10 Code. Condusion Spondylolisthesis ICD - 10 coding must be combined with medical imaging diagnosis. In order to improve the quality assurance of ICD - 10 coding, we must read the medical record carefully and predominate the ICD-axis.