结核类疾病编码分析

Coding Analysis in Tuberculosis Diseases

疾病诊断是我国疾病分类的基础,国际疾病分类(ICD)是根据疾病的某些特征,按照规则将疾病分门别类,并用编码的方法进行表示。疾病的分类受病因、部位、临床表现和病理4个方面的影响,并按照类目、亚目和细目来进行编码。在ICD-10中,肺结核类目A15和A16的分类轴心不是部位,而是实验室对结核杆菌检查的证实情况,结核类疾病诊断是相对复杂及相似,时常会出现相似的诊断但编码差别很大的情况,编码员在对其进行分类时必须结合病案首页和阅读病案内容来做到准确的分类。本文通过对肺结核、非活动性肺结核、结核性胸膜炎、咯血、肺结节、肺结核术后等常见易错编码进行分析,查找编码错误原因,提出对策及建议提高诊断和编码的准确性。

Disease diagnosis is the basis of disease classification in our country. The International Classification of Diseases(ICD) is arranged into sorts according to certain characteristics of dieases and rules, and express them by coding. The classification of diseases is affected by the four aspects: etiology, location, clinical manifestation and pathology, and it is coded according to categories, subcategories and details.In ICD10, the classification axis of tuberculosis classes A15 and A16 is not the location, but the laboratory confirmation of tuberculosis bacillus examination. In addition, the diagnosis of tuberculosis is relatively complex and similar, and there are often similar diagnosis with different codes. When classifying diseases, coders must combine the front page with reading the whole medical record to classify it accurately. In this paper, we analyzed the codes of common misdiagnosis of tuberculosis department, such as pulmonary tuberculosis,inactive pulmonary tuberculosis, tuberculous pleurisy, hemoptysis, pulmonary nodules, pulmonary tuberculosis after operation, and found out the causes of misuse, putting forward countermeasures and suggestions to explore the accurate codes.