病因学诊断在肺炎ICD-10编码的意义

The importance of etiological diagnosis on ICD-10 coding of pneumonia

目的强调病因学诊断在肺炎ICD-10编码中的意义,提高肺炎编码的准确性。方法回顾分析佛山市中医院2013年6月1日至2014年5月31日第一诊断为肺炎的病例517例,按国际疾病分类第十版(ICD-10)的疾病编码原则,分析其编码错误的原因。结果 115例痰培养阳性的病例中,只有41例在首页上标明菌种。在编码到J15.9和J18.9的475例病例中,有83例能根据细菌学培养结果重新编码到其他位置。结论规范肺炎的临床诊断,强调病因学诊断。提高编码员的综合素质能力,熟悉各种细菌性肺炎的ICD-10编码。

Objective Emphasize the importance of etiological diagnosis on ICD-10 coding of pneumonia and enhance the accuracy of code of pneumonia. Methods Retrospectively review was performed on 517 patients who were first diagnosed as pneumonia in Foshan Hospital of Traditional Chinese Medicine hospital from Jun 2013 to May 2014 to find out the cause of wrong ICD-10 coding. Results 1. Among 115 cases of culture-positive of sputum specimens, only 41 had strains written down on front sheet of medical record. 2. Among 475 cases classified to code J15.9 and J18.9, 83 needed to be corrected according to the result of bacterial culture.Conclusion 1. Standardize the diagnosis of pneumonia and attach importance to etiological diagnosis. 2. Improve the knowledge of employees who work on disease code identification. Let them get familiar with ICD-10 code of bacterial pneumonia