血液透析手术操作编码的探讨

Discussion on Operations Coding of Hemodialysis

目的通过对血液透析患者的手术操作编码的常见错误及正确编码进行对比和分析,为编码工作提供正确指导。方法本文根据某医院病案编码工作实践,对血液透析手术操作的常见错误编码、正确编码及其查找过程进行阐述。结果行股静脉穿刺置管术的血液透析患者手术操作编码应为38.95与39.95,行血管内瘘吻合术的血液透患者的手术操作编码应为39.27与39.95。结论在血液透析手术操作编码工作中,依靠计算机检索容易导致错误编码甚至漏掉重要编码。为保证编码准确完整,编码员需注重使用ICD-9编码工具书,正确选择、变换主导词,以及相关临床知识的学习和积累。

Objective To provide correct guidance for the coding work through a comparative analysis on the common mistakes and correct operation coding of hemodialysis patients. Method According the working practice in our medical records management, this paper described the common mistakes and the correct ways to the right coding in hemodialysis operations. Result The correct operations coding of hemodialysis patients with femoral vein catheterization were 38.95 and 39.95, while patients with vascular fistula anastomosis were 39.27 and 39.95.Conclusion Computer based searching was easy to cause mistakes even missing important operations coding in the work of operations coding of hemodialysis patients. In order to ensure the accurate and complete coding, code workers should put emphasis on the application of the ICD-9 coding books, and make a right choice of selecting, convert dominant words and accumulate clinical knowledge simultaneously.