子宫静脉内平滑肌瘤病编码质量分析

Analysis of Encoding Accuracy of Intravenous Leiomyoma in Uterine

目的提高子宫静脉内平滑肌瘤病编码准确率。方法选取某院2012年1月-2017年8月住院手术治疗且经病理证实的病例9份,ICD编码为静脉内平滑肌瘤病的病例10份,对所有病例的疾病编码进行复核,对存在的问题进行分析汇总。结果 9份经病理证实为子宫静脉内平滑肌瘤病的病例中,2份病例出现编码错误,正确率为77.8%;10份ICD编码为该病的病例中,3份出现编码错误,正确率为70%;总涉及病例数12例,正确编码例数7例,错误5例,总正确率为58.3%。结论子宫静脉内平滑肌瘤病编码错误的主要原因为编码员医学知识匮乏、特殊病种管理意识淡漠等,需提高编码人员综合素质水平,加强编码质量监督检查,提高疾病分类质量。

Objectives To improve the encoding accuracy of intravenous leiomyomatosis in uterine. Methods To choose 9 cases who were operated and confirmed by pathology in a hospital from January 2012 to August 2017, 10 cases with ICD coding of intravenous leiomyoma disease, and review of all cases of disease coding, analyze the problems existing in the summary. Results In 9 cases of leiomyomatosis of the uterine vein, 2 cases were incorrectly coded and the correct rate was 77.8%. In 10 cases of ICD coding, 3 of the cases showed coding errors with a correct rate of 70%. The total number of cases was 12 cases, 7 cases were correctly coded, 5 cases were wrong, and the total accuracy was 58.3%. Conclusions The main causes of uterine intravenous leiomyoma of the coding errors included coders lack of medical knowledge, special disease management consciousness and so on. We should improve the coding personnel overall quality level, strengthen the coding quality supervision and inspection method to improve the quality of disease classification.