胆囊炎的病理分型对ICD-10编码的影响分析

Analysis of Calculous Cholecystitis Etiology Effect on ICD-10 Encoding

目的探讨胆囊炎的病理分型,以利于病案编码员对其做出确切的国际疾病分类ICD-10编码。方法通过"病案编目"管理系统,以胆囊炎为主引导词,检索出第三军医大学大坪医院2006年12月至2011年11月临床主要诊断为胆囊炎的病案1554例进行回顾性分析,根据胆囊炎病理分型为标准、依据ICD-10编码分类要求予以分析讨论。结果 1554例胆囊炎中,共有363例病案编码错误,总错误编码率为23.16%。其中,慢性胆囊炎病例数最多、比率最大,达1262例,占81.21%,它的编码错误率也是最高,达320例,占20.59%;其次编码错误率依次为:是急性单纯性胆囊炎2.06%、急性坏疽性胆囊炎0.38%、急性化脓性胆囊炎0.26%、胆囊穿孔0.13%。结论胆囊炎因病理分型不同,对应ICD-10编码也不相同,病案编码人员需正确分析胆囊炎的各种病理分类,细分各种类型,切不可主观地给出编码。对慢性胆囊炎、急性单纯性胆囊炎、急性化脓性胆囊炎、急性坏疽性胆囊炎及胆囊穿孔等类型要逐一鉴别,保证编码的质量。

Objective To discuss cholecystitis pathology type, in order to facilitate the coder to make precise ICD-10 code of the international classification of diseases. Methods Retrospective analysis on 1, 554 cases of cholecystitis as the main clinical diagnosis during Dec. 2006 and Nov. 2011 through ＂directory＂ management system, with cholecystitis as the main guiding words from Daping Hospital was done. , discussion was done according to cholecystitis pathological type and ICD-10 coding. Results Among the 1554 cases of cholecystitis,363 cases were wrongly coded,the total coding error 23.16%. Chronic cholecystitis had the lar- gest case number and percentage, amounted to 1262, occupying 81.21% ,its coding error rate was the highest as well, up to 320 cases, accounting for 20.59% ; cases of coding error in order were ： acute suppurative chole- cystitis ,2.06% ;acute gangrenous cholecystitis,0.38% ; acute suppurative cholecystitis ,0.26% ;gallbladder perforation,0.13%. Conclusion Different pathological types of cholecystitis have different ICD-10 codes, coders are required to correctly analyze the cholecystitis pathological classification, subdivision of various types, subjective coding is strictly forbidden. Chronic cholecystitis, acute suppurative cholecystitis, acute sup- purative gallbladder inflammation, acute gangrenous cholecystitis and gallbladder perforation should be identi- fied one by one, to ensure the coding quality.