椎板回植术的ICD-9-CM-3编码探讨

Lamina Replantation's ICD-9-CM-3 Coding Research

目的:探讨胸腰椎板回植术准确的ICD-9-CM-3编码。方法:以2014年1月~2016年12月来本院就诊的40例椎管内肿瘤患者的病案为研究对象,并详细研究其中12例行肿瘤切除+椎板回植术(后路)患者的病案。首先与临床医生进行沟通,然后查阅工具书和文献,再在高年资编码员主持下进行科内讨论,最后确定该手术的编码。结果:椎板回植术(后路)准确的ICD-9-CM-3编码为78.09。结论:在对临床新开展手术操作编码的之前,应该将患者的病历进行深入分析,并与临床医生沟通,再查阅文献资料,在资深编码员主持下进行详细讨论,最后才能确定编码。在给予ICD-9-CM-3字典库临时编码字段的时候,应考虑与临床医生的书写习惯相结合。

Objective:To research lamina replantation’s accurate ICD-9-CM-3coding.Methods:40cases of spinal canal tumor from January2014to December2016inour hospital were analyzed.Made detail researched at12case of which performed tumor resection and lamina replantation.Communicated with the clinicaldoctor,refer to documents and tool books,made a detail discussion which directed by senior coder,before made accurate coding of the operation.Results:The accurate ICD-9-CM-3coding of lumbar lamina replantation is78.09.Conclusion:Before coding the newly-commenced operation,made a deep researchof the medical case,communicated with the clinical doctor,refer to documents,and made detail discussion with senior coder.Considered with the doctor’shandwriting habit when appended the temporary code field of the newly-commenced operation in the ICD-9-CM-3dictionary.