某院对ICD-9-CM-3中易错“不包括”编码的分析

Analysis of Error-prone "excluding" Coding in ICD-9-CM-3

目的 ICD-9-CM-3编码中有些附加说明的"不包括",不注意就会出现编码的错误。分析错误原因以达到提高编码质量的目的。方法利用病案首页编码录入系统,检索出2017年某院胸骨后甲状腺肿并行甲状腺部分或全部切除的病案124例;鼻中隔穿孔同时伴偏曲并行鼻中隔穿孔修补术和鼻中隔偏曲矫正术的病案1例;喉癌行全喉切除术的病案67例;视网膜脱离行视网膜裂伤修补术的病案959例;胆道结石并做胆道取石手术的病案141例。通过重新核对手术记录,统计手术操作编码错误例数与其实际使用例数的比值,得到手术操作编码的错误率。结果合计检索出总病案数为1292例,编码错误的767例,总错误率为59%。其中胸骨后甲状腺肿病案124例,编码错误113例,错误率91%;鼻中隔穿孔同时伴偏曲的病案1例,编码错误1例,错误率100%;喉癌并做全喉切除术67例,编码错误18例,错误率27%;视网膜脱离行视网膜裂伤修补术的病案959例,编码错误497例,错误率52%;胆道结石并做胆道取石手术的病案141例,编码错误138例,错误率98%。结论分类中的"不包括"直接影响手术操作编码的准确,编码员需提高编码水平,保障编码质量。

Objective In the ICD-9-CM-3 coding, there are some additional ＂excluding＂, and there will be coding errors if we don＇t pay attention to. Analyze the causes of errors, improve the quality of coding. Methods 124 cases of partial or total thyroidectomy in a certain hospital in 2017 were retrieved by the transmission machine retrieval system, 1 cases of nasal septum perforation accompanied by partial perforation of nasal septum and correction of nasal septum deviation, 67 cases of laryngectomy with total laryngectomy, retinal detachment and retinal cleft. There were 959 Cases of wound repair, 14l cases of cholelithiasis and choledocholithotomy. By rechecking the operative records, and comparing the ratio of coding error cases to the actual number of cases, the error rate of operative coding is obtained. Results In total, 1292 cases were retrieved, 767 cases were coded, and the total error rate was 59%. Among them, there were 124 cases of posterior sternum goitre history, 113 cases of coding error, 91% error rate, 1 cases of nasal septum perforation and deviation, 1 cases of coding error, 100% error rate, 67 cases of laryngectomy and total laryngectomy, 18 coding errors, 27% error rate, 959 Cases of retinal detachment repair of retinal membrane laceration, coding error. 497 cases were mistaken, the error rate was 52%. 141 cases of biliary calculi and choledocholithotomv were performed, 138 cases were coded, and the rate of error was 98%. Conclusion The ＂excluding＂ in classification directly affects the accuracy of operative coding. The coder needs to raise the coding level and guarantee the quality of coding.