疾病分类编码分类方法应用

Application of Disease Classification Coding and Classification Method

目的探讨肝癌ICD-10疾病编码及手术ICD-9-CM-3编码问题。方法根据肝癌的病因、临床表现及病理分型以及手术的范围、入路方式及伴随其他操作进行手术编码分析。介绍肝癌疾病和手术分类原则以及查找编码方法,并对肝癌的疾病及手术编码中遇到的各种问题给予解答。结果手术和医疗操作诊断都是全面了解医疗事件和获取疾病信息的重要环节,也是患者病案首页的重要组成部分,肝癌的手术操作名称及术式都会影响到编码,名称不规范可导致编码的误差,正确的手术编码有赖于医生对疾病名称和手术操作名称的正确书写。结论肝癌的疾病编码应该结合手术明确病变部位,而手术切除的范围及使用的手术方法直接影响肝癌手术操作编码,临床医生和病案编码人员对疾病的专业知识及掌握编码知识具有重要意义。

Objective To investigate the ICD-10 disease coding and ICD-9-CM-3 coding in hepatocellular carcinoma.Methods Based on the etiology of liver cancer,its clinical manifestations and pathological classification as well as the scope of its surgical treatment,approach and accompanying procedures,surgical coding were analyzed.Also,liver cancer as a disease was introduced,and its surgical classification was elaborated with methods to locate coding.Questions arising out of it were answered.Results The diagnosis of disease and medical operation are both important aspects of medical events and disease information acquisition.It is also an important part of the patient’s medical record.The names of surgical operations and surgical procedures of liver cancer affect the coding.Non-standard designation can lead to coding error.So correct surgical coding depends on the doctor’s correct designation of the disease and also the surgical procedure.Conclusion While the disease coding of HCC should be combined with the operation to identify the lesion,the scope of the surgical removal and the operation method used directly affect the operation coding of liver cancer.So it is important to emphasize the importance of the knowledge about diseases and their coding for clinicians and medical record coders.