妊娠滋养细胞疾病的ICD-10编码案例分析

ICD-10 Coding Cases Analysis of Gestational Trophoblastic Diseases

妊娠滋养细胞疾病是指胚胎的滋养细胞发生异常增殖而形成的一组疾病,包含葡萄胎、侵蚀性葡萄胎、绒毛膜癌及胎盘部位滋养细胞肿瘤。根据ICD-10分类规则,葡萄胎分为部分性葡萄胎和完全性葡萄胎,分别编码为O01.1和O01.0;侵蚀性葡萄胎编码为D39.2;绒毛膜癌编码为C58;胎盘部位滋养细胞肿瘤编码为D39.2;未明确诊断的妊娠滋养细胞疾病编码为O01.9。然而在实际编码过程中,该组疾病不易被准确编码。通过选取6例妊娠滋养细胞疾病的典型病例进行回顾分析,探讨该组疾病诊断编码,指导编码人员准确编码,提高该类疾病的编码质量。

Gestational trophoblastic disease （GTD） is a embryonic trophocyte. It includes four types of hydatidiform group of diseases caused by abnormal proliferation of mole, invasive mole, choriocarcinoma, placental site trophoblastic tumour, hydatidiform mole is divided into the partial type and the complete type. According to the ICD-10, the code for partial hydatidiform mole is 001.1, for complete hydatidiform mole is 001.0, for both invasive mole and placental site trophoblastic tumour is D39.2 and for choriocarcinoma is C58. However, in practice, these diseases arc usually difficult to be coded exactly. In this article, 6 typical cases are selected to be retrospectively analyzed, aim to guide the coder how to code the gestational trophoblastic disease exactly and enhance the quality of encoding.