疾病诊断名称相似的ICD-10编码实例分析

ICD-10 Coding Cases Analysis on Diseases with Similar Diagnosis Names

通过对日常工作中遇到的某些诊断名称相似的疾病进行ICD-10编码分析后,总结出疾病诊断的细微差别对ICD-10编码影响较大。某些诊断仅一字之差,或仅多一修饰词,疾病性质就发生了改变,即由普通妇科疾病转变为妇科肿瘤,或由良性肿瘤转变为恶性肿瘤,导致其ICD-10编码完全不同。某些相似的诊断即使疾病性质相同但不属于同种疾病,ICD-10编码也不相同。欲提高对此类情况分类的准确性,编码员需具备扎实的医学基础、良好的工作习惯和较高的编码水平,只有这样才能确保疾病分类工作的准确性,以便更好地为医、教、研服务。

Through conducting ICD-10 coding analysis on diseases with similar diagnosis names in our daily work, we concluded that little difference could make big effect on the ICD-10 coding of the diseases. The character of the diseases could be changed by only a different word or qualifier. For example, the common gynecological disease could change into tumor, or transfer into cancer from benign tumor, which resulted in the absolute difference in ICD-10 coding. And also the ICD-10 coding of some similar diseases was different although they had same characters but with different homogeneity. In order to improve the accuracy of such situations, the coders should have concrete basis of medical knowledge, good work habit and better coding skill, only by this way could guarantee the accuracy of the diseases classification work as well as provide service for the three aspects included medicine, teaching and research.