脊柱骨折ICD编码分析

Analysis on ICD Coding of Spinal Fracture

脊柱骨折的原因有外伤性骨折、病理性骨折、先天性骨病导致的骨折等。临床常见类型为病理性骨折和外伤性骨折,国际疾病分类(ICD-10)将其分类在第十三章肌肉骨骼系统和结缔组织疾病、第十九章损伤中毒和外伤的某些其他后果。手术及操作分类(ICD-9-CM-3)中涉及到脊柱骨折手术操作的编码有第二章神经系统手术、第十五章肌肉骨骼系统手术。在分类过程中,要详细阅读病历资料,了解疾病发生发展以及诊疗经过,根据病因、部位、病理、临床表现及治疗方法等情况综合分析予以编码。本文选取5例脊柱骨折典型病例进行回顾性分析,指导编码员准确编码,提高编码工作质量。

The causes of spinal fractures include traumatic fracture,pathological fracture and the fracture caused by congenital osteopathy,etc. The common clinical types are pathological and traumatic fracture,the ICD-10 classifies them in the chapter 13 of the musculoskeletal system and connective tissue disease,and the chapter 19 of injury,poisoning and certain other consequences of external causes. In the ICD-9-CM-3,the content of coding related to operation of spinal fracture is included in the chapter 2： operations on the nervous system,and in the chapter 15： operations on the musculoskeletal system. In the process of classification,we need to read the medical records in detail,understand the occurrence and development of the disease and the diagnosis and treatment process,and make comprehensive analysis based on the etiology,location,pathology,clinical manifestations and treatment methods and code it. In this paper,we selected 5 typical cases of spinal fractures to conduct a retrospective analysis to guide the coders to coding correctly and improve the quality of the coding work.