165份膀胱癌根治术的ICD-9-CM-3编码错误分析

Analysis of ICD-9-CM-3 Coding Error in 165 Cases of Bladder Cancer

目的对膀胱癌根治术中编码错误原因进行查找分析,提高编码准确性。方法病案管理系统检索出院时间2017年1月-2017年12月行膀胱癌根治术病案165份,按照ICD-9-CM-3编码原则,对手术编码进行分析核查。结果重新阅读病案发现编码错误45份,错误率27.3%,其中输尿管皮肤造口错编为原位回肠膀胱术21份,占46.7%;淋巴结清扫漏编15份,占33.3%;输尿管-回肠皮肤造口错编输尿管皮肤造口4份,占8.9%;前列腺切除术多编3份,占6.7%;输尿管皮肤造口多编1份,占2.22%;机器人辅助外科治疗漏编1份,占2.22%。结论根治性膀胱切除术术式多种多样,编码员必须有高度责任心、熟练掌握ICD编码原则和临床知识,在实际工作中养成按照编码操作步骤查询、阅读病案和与临床医师沟通的习惯,不断提高自身编码水平以确保编码质量。

Objective To find and analyze the cause of coding errors in radical resection of bladder cancer,improve coding accuracy. Methods The medical records management system retrieved 165 patients with bladder cancer undergoing radical surgery from January 2017 to December 2017. In accordance with the ICD-9-CM-3 coding principle,the operative coding is analyzed and checked. Result Re-read medical records find 45 wrong codes,error rate 27.3%,ureteral skin stoma wrong input into orthotopic ileal cystectomy 21 cases,46.7%; Lymph node dissection missing input 15 cases,33.3%; skin ureter-ileostomy wrong input intocutaneous ureterostomy 4 cases,8.9%; prostatectomy superfluous input 3 cases,6.7%; intocutaneous ureterostomy superfluous input 1 cases,2.22%; laparoscopic robotic assisted procedure missing input 1 cases,2.22%. Conclusions Bladder cancer radical mastectomy type many,the coder must have a high sense of responsibility,proficiency in ICD coding principles and clinical knowledge,in the actual work in accordance with the coding steps to find,read medical records and communicate with clinicians habits,and constantly improve their coding level to ensure the quality of coding.