乳房肿瘤诊断ICD-10编码的常见问题及对策分析

Analysis of Common Problems and Countermeasures of ICD-10 Code for the Breast Tumor Diagnosis

目的了解某院乳房肿瘤ICD-10编码的使用情况,编码中常见的问题,梳理正确的编码思路,探讨更准确的编码方法,提高编码质量。方法检索某院住院部2013年-2016年期间收治的乳房肿瘤患者共计10 813人次的病案资料,对病案首页主要诊断的编码情况进行检查。结果主要诊断的编码准确率是97.94%,此次检查过程中发现主要诊断的编码存在的问题如下:乳房肿瘤有多个病理诊断的病案没有按编码原则查找编码,编码准确率不足80%;以乳房恶性肿瘤为主要诊断的病案部位编码查找不准确,编码准确率约为94.78%;运用特殊诊疗方法的病案编码查找步骤不完整,编码准确率在97.43%左右。结论乳房肿瘤ICD-10编码不能简单的按病案首页书写的诊断编码。编码工作人员应该认真阅读病案资料正确判断肿瘤部位编码和性质,灵活运用编码规则谨慎编码,在编码过程中减少差错率,提高编码质量。

Objective Understand the current state of the ICD-10 code for the breast tumor in my hospital,analyze the common problem,combing the correct coding ideas,discussmore accurate coding methods,to improve the quality of ICD-10 code.Methods Based on the 10813 breast tumor cases in the inpatient department of my hospital from 2013 to 2016,we check the main diagnosis and code for the first page in their medical record.Results We found that the accuracy of thecode for the main diagnosis is about 97.94%.In addition,in these medical records,some common problemsare found in the main diagnostic,such as for breast tumor with multiple pathological diagnoses,the accuracy is less than 80%; for the medical records with the malignant tumor of breast as the main diagnosis,the accuracy is 94.78%; the code process is not integrity for the special treatment,the accuracy is about97.43%.Conclusions ICD-10 code for the breast tumor should be completed not only based on the first page.The coding staff should read the medical records carefully and correctly judge the coding and nature of the tumor site,flexibly use the coding rules to code carefully,reduce the error rate in the coding process,and improve the quality of the coding.