椎管内占位性病变ICD-10编码案例分析

Cases Analysis on ICD-10 Coding of Intra-spinal Occupying Lesions

椎管内占位性病变是发生在脊髓、硬脊膜、神经根等部位的一系列疾病的统称,其类型复杂而多样,包括椎管内脓肿、囊肿、肿瘤等,所涉及的ICD-10章节和编码不同。因此,在实际工作中容易出现编码错误。本文选取7个案例对不同类型的椎管内占位性病变进行编码分析,主要涉及的编码有G06.1、G96.1、D18.0、D32.1、D33.4、C70.1等,指出编码的易错点和诊断的难点。在遇到椎管内占位性病变的病例时,临床医师需明确病变的部位、病理等情况,做出正确的疾病诊断;编码员需认真查看病历,了解病变的病理学、解剖学、影像学等知识,并及时查阅编码工具书,综合分析后得出准确的编码;同时,临床医师和编码员需加强沟通,提高椎管内占位性病变的诊断正确率和编码准确率。

Intra-spinal occupying lesions are a series of diseases occurring in the spinal cord,dura mater,nerve root and other parts.Their types are complicated and diverse(including intra-spinal abscess,cyst,tumor and so on),and the ICD-10 chapters and coding involved are different.Therefore,coding errors are easy to occur in practical work.In this paper,we selected seven cases to analyze the coding of different types of intra-spinal occupying lesions.And the main codes involved were G06.1,G96.1,D18.0,D32.1,D33.4,C70.1,etc.What’s more,we further showed the error points of coding and the difficulties of diagnosis.When encountering the medical records of intra-spinal occupying lesions,the clinicians should clearly indicate the location and pathology of the lesions and make a correct diagnosis of the disease,and the coders should carefully check the medical records,understand the pathology,anatomy,imaging and other knowledge of the lesions,consult the coding reference book in time and get the accurate coding after comprehensive analysis.Meanwhile,the clinicians and the coders should strengthen communication to improve the diagnostic accuracy and coding accuracy of intra-spinal occupying lesions.