国际疾病和手术分类编码在口腔医学中的应用

The Application of International Classification of Diseases and Procedures Coding in Stomatology Medicine

目的通过分析国际疾病和手术分类编码在口腔医院使用频率,为口腔诊断编码的规范使用提供依据。方法对某院2009年-2013年出院患者的口腔疾病和手术编码的使用频度和相似度进行统计分析。结果国际疾病分类(北京临床版)中涉及口腔医学的诊断编码为937条,占总编码量的4.39%;该院5年间收治23987例患者,75%以上患者的病种集中在国际疾病分类的肿瘤(C和D)、消化系统疾病(K)、先天性畸形(Q)章节;5年间总的诊断编码量为788条,占口腔诊断编码的84.1%;该院手术编码占口腔手术编码的75.14%-98.59%之间,占总编码的5.60%-7.37%之间;80%的诊断和手术编码的相似度分别为61.58%和47.40%。结论国际疾病和手术分类在口腔医学中的使用率相对较低,建议采用国际疾病分类牙科和口腔学分册(ICD-DA)的分类规则细化口腔诊断编码,以进一步满足临床需求。

Objective To analyze the utilization frequency of the International Classification of Diseases and Procedures coding in stomatology hospital, and provide the basis for the use of oral diagnostic coding. Methods To conduct an analysis on the utilization frequency and similarity of diseases and surgical coding in hospital from 2009 to 2013. Results There were 937 codes involved in oral medicine in Beijing ICD-10, just accounting for 4. 39%. 23, 987 patients were treated in the past five years and more than 75% oral diseases were concentrated in the International Classification of Diseases of the CD, K, Q chapters. The total diagnostic codes were 788, accounting for 84. 1% in oral diagnosis codes. Surgery codes accounts between 75.14 and 98.59% in oral surgery coding, and accounts between 5.60% and 7.37% in Beijing ICD. 80% similarity diagnosis and surgery codes were 61.58% and 47.40%. Conclusions The utilization rate of International Classification of Diseases and Procedures is relatively low, so we recommend refine the oral diagnosis coding according to the ICD-DA in order to meet the clinical needs further.