食管损伤ICD-10编码分析

Analysis of ICD-10 Coding of Esophageal Injury

目的根据食管损伤的病因及损伤部位,对食管损伤作出正确编码。方法对某院2010年1月1日-2014年4月30日出院诊断为食管损伤、食管破裂、食管穿孔的病案进行回顾性分析,依据《疾病和有关健康问题的国际统计分类》(ICD-10第二版)的分类要求,对食管损伤进行编码。结果 52份诊断为食管损伤、食管破裂、食管穿孔的病案中,食管异物引起的食管损伤、破裂、穿孔33份,占63.46%;自发性食管破裂、穿孔10份,占19.23%;创伤引起的食管破裂5份,占9.62%;医源性食管损伤、破裂、穿孔4份,占7.69%。结论食管损伤、破裂、穿孔作为临床诊断名称,不同的病因、不同的损伤部位有着不同的编码,编码员必须通过阅读病案资料,明确病因及部位,从而保证编码的正确性。

Objective To make correctly coding to esophageal injury according to the pathogenesis and lesion location. Methods To conduct a retrospectively analysis on the patients with Discharge diagnosis for esophageal injury, esophageal disruption and esophageal perforation from January 1st 2010 to April 30th 2014, then perform coding to esophageal injury according to the classified demand of the ＂International statistical classification of diseases and related health problems＂ （ICD-10 second edition）. Results Among the 52 cases which were diagnosed as esophageal injury, esophageal disruption and esophageal perforation, there were 32 cases caused by foreign bodies in esophageal, which accounted for 63.4%, there were 10 cases caused by spontaneous esophageal disruption, which, accounted for 19.23%, there were 5 cases caused by trauma, which accounted for 9.62%, and there were 4 cases caused by iatrogenic injury, fracture and perforation, which accounted for 7.69%. Conclusions As the clinical diagnosis names, esophageal injury, disruption and perforation have different coding when their pathogenesis and lesion location are unlike. The coders have to make the pathogenesis and location clear through reading clinical records, and ensure the accuracy of coding.