成熟性囊性畸胎瘤和皮样囊肿及表皮样囊肿的ICD-10编码

ICD-10 Coding for Mature Cystic Teratomas and Dermoid and Epidermoid Cysts

根据ICD-10分类原则,检索某医院以皮样囊肿、成熟性囊性畸胎瘤为主要形态学编码和表皮样囊肿为主要疾病编码的病案,分析皮样囊肿和表皮样囊肿、皮样囊肿和成熟性囊性畸胎瘤的编码区别,形态学编码为m9080-m9084的病案363例,错误编码14例,占3.9%,其中首页录入错误2例。主要诊断编码为L72.0的病案289例,错误编码1例,占0.3%。错误的主要原因是对所编码的3种疾病的病理特点缺乏了解,病案首页录入不认真等。选取5例错误编码的典型病例进行回顾性分析。编码员在进行疾病编码时除熟练掌握编码原则外,还要不断学习积累医学知识,做到对疾病有全面了解的基础上再进行分类,以提高首页录入的质量。

According to ICD-10, the medical records of dermoid cyst, mature cystic teratoma and epidermoid cyst in a hospital were retrieved, and dermoid cyst and epidermoid cyst, dermoid cyst and mature cystic teratoma were analyzed. The coding differences of fetal tumors were analyzed retrospectively in 5 cases of miscoding. 363 cases with morphological coding of m9080-m9084, 14 cases with erroneous coding, accounting for 3.9%, of which 2 cases had errors in homepage entry. The main diagnostic codes were L72.0 in 289 cases and 1 case, accounting for 0.3%. The main reason for summarizing errors lies in the lack of understanding of the pathological characteristics of the three diseases coded;secondly, the inadequate entry of the front page of medical records leads to errors in the entry. In addition to mastering the coding principles, we should constantly learn and accumulate medical knowledge to classify diseases on the basis of a comprehensive understanding of diseases and improve the quality of home page entry.