糖尿病的ICD-10编码探讨

Investigation on the ICD-10 Coding of Diabetes

目的分析探讨糖尿病分型、糖尿病并发症情况的编码。方法利用"疾病和有关健康问题的国际统计分类第十次修订本(ICD-10)"对主要诊断为糖尿病E14.-的180份病案进行分析。结果医师诊断糖尿病,编码于E14.-的180份病案中,确诊糖尿病类型的有156份,占全部病案86.67%;其中Ⅰ型糖尿病的有13份,占8.33%,Ⅱ型糖尿病有130份,占72.22%,其他类型糖尿病有12份,占7.69%,妊娠期糖尿病1份,占0.64%。结论编码员对糖尿病编码时要认真阅读病案及与临床医师沟通,确定糖尿病分型,再结合糖尿病伴随的并发症情况进行分析,按照编码规则进行准确编码。

Objective To analyze and investigate the classification and coding situation of diabetes.Methods To conduct analysis on the 180 cases of medical records diagnosed with diabetes E14.-according to the ＂The International Statistical Classification of Diseases and Health Related Problems ICD-10 ＂.Results In the 180 cases of medical records diagnosed with diabetes and coding in E14.-,there were 156 cases were confirmed diagnosed,which accounted for 86.67％,in which there were 13 cases of Ⅰ type diabetes,which accounted for 8.33％,130 cases of Ⅱ type diabetes,which accounted for 72.22％,12 cases of other types of diabetes,which accounted for 7.69％,1 case of pregnancy diabetes,which accounted for 0.64％.Conclusions Coders should read the medical records carefully and communicate with clinical doctors while making coding of diabetes,confirm the classification,then conduct analysis combined with the complications company with diabetes,and make correct coding according to the rules finally.