肝胆外科3例疑难疾病的编码案例分析

Coding Analysis on Three Cases of Difficult Diseases in Department of Hepatobiliary Surgery

ICD-10现在广泛应用于临床路径管理、按病种付费、医院评审、重点学科评审、传染病报告中,编码的正确性至关重要。在实际编码过程中会遇到比较难于查找的疾病,本文通过分析腹腔间隔室综合征、胰胆管合流异常、Mirizzi综合征3例肝胆外科疑难疾病的编码查找过程,总结查找疑难编码时,要仔细分析病案资料,正确理解疾病本身,有效转换主导词;新病种或新疾病合理使用残余类目;对于分类到同一类目下的疾病名称应适当给予扩展码以示区别,以确保疾病分类编码的准确性。

The ICD-10 has widely applied in aspects such as clinical pathways management, payment of type disease, hospital review, accreditation of key discipline and infectious diseases report, the accuracy of coding is of great significance.In the actual coding process, we often come across diseases hard to find. Through the analysis on the coding finding process of 3 cases of difficult diseases in department of hepatobiliary surgery included abdominal interval syndrome,confluence pancreatic abnormalities and Mirizzi syndrome,this article summarized the experience of finding difficult coding, which included analyzing medical records materials carefully, understanding diseases situation accurately, changing main words effectively and applying remnant items of new diseases and entities. We should put suitable extended code for the names of diseases classified under the same subtitle, so as to guarantee the accuracy of diseases classification coding.