输卵管系膜囊肿手术编码质量分析

Quality Analysis on the Operations Coding of Mesosalpinx Cyst

目的规范输卵管系膜囊肿手术编码。方法采用输卵管系膜囊肿为检索词,通过病案统计管理系统检索出2007年7月-2015年3月188份病案,对其中94份行输卵管系膜囊肿手术的年份区间、手术名称、手术编码等进行统计分析。结果 2007年-2008年间输卵管系膜囊肿手术对应两个手术名称及编码,占20.21%,因编码员分类错误占6.38%。2009年-2014年间ICD-9-CM-3临床版字典库中取消输卵管系膜囊肿切除术和输卵管系膜囊肿剥除术及对应编码后,将输卵管系膜囊肿手术编码靠在输卵管病损切除术(或腹腔镜下输卵管病损切除术)和阔韧带病损切除术,分别占43.62%和17.02%。2015年1月-3月统一规范了输卵管系膜囊肿手术名称及编码,占5.32%。结论规范ICD-9-CM-3临床版字典库,提高编码人员的综合素质,规范临床医师手术名称,才能提高输卵管系膜囊肿手术编码质量。

Objective To specify and standardize the operations coding of mesosalpinx cyst. Methods 188 cases of medical records were selected from the medical record statistic system by using the key word of the mesosalpinx cyst from July 2007 to March 2015. Then conducted statistical analysis on aspects of time period, surgery titles and operations coding on the 94 cases who were received the operations. Results Between 2007 and 2005, we found two different nomenclatures of operations corresponding to the mesosalpinx cyst surgery in 20. 21% of the medical record sample and found classification error by coders in 6. 38% of the sample. After cancelling the titles of the mesosalpinx cyst resection and the mesosalpinx cyst removal operations in the clinical dictionary database of ICD-9-CM-3 coding between 2009 and 2014, excision lesion fallopian tube （or laparoscopic excision lesion fallopian tube）, and excision lesion broad ligament are possible choices for the mesosalpinx cyst operations, representing 43.62% and 17.02% of the sample, respectively. The title and coding of the mesosalpinx cyst operations were unified at the beginning of 2015. 5.32% of the sample happened during this period. Conclusions We should standardize the clinical dictionary database of ICD-9-CM-3 coding, enhance the coding ability for the classification of operations and specify the rules for clinicians of filling in the diagnosis of operations, thus could we improve the operations coding quality of mesosalpinx cyst.