上睑下垂的编码质量分析

Coding Quality Analysis of Ptosis

目的通过分析某院2018年上睑下垂的相关编码数据,探讨编码错误的原因,提高编码员对上睑下垂诊断与手术编码的准确性。方法利用某院病案信息查询系统调取2018年1月1日-2018年12月31日住院患者病案首页主要手术编码(ICD-9-CM-3)为08.31-08.37的病例352例,由资深编码员逐一核对所有病例的疾病诊断和手术编码,并进行统计分析。结果16份住院病案首页是因为临床医师主要诊断填写错误导致ICD编码错误,错误率为4.5%;有12份住院病案首页是临床医师主要诊断书写错误,但编码员仔细阅读病历后编码正确。错误编码主要是将先天性上睑下垂归类到后天性上睑下垂;272份住院病案首页医师未明确手术术式,编码员编码错误76例,错误率27.9%;80例住院病案首页医师明确手术术式,编码员编码错误4例,错误率为0.05%。结论编码员应仔细阅读病历记录和手术记录,遇到问题主动与临床医师沟通。不断提升自身临床专业知识,加强工作责任心,以提高病案编码质量。

Objective To analyze the coding data of blepharoptosis in a hospital in 2018,discuss the causes of coding errors,and improve the accuracy of the coder’s diagnosis and surgical coding of blepharoptosis.Methods 352 medical records with ICD-9-CM-3 of 08.31-08.37 in 2018 were retrieved by using the medical record information query system.The senior coder checked the diagnosis and operation codes of all cases one by one and analyzed them.Results 16 cases had the main diagnostic coding errors due to the writing errors on the first page of doctors,with the error rate of 4.5%;12 cases had the writing errors on the first page of doctors,and the coding was correct after the coder carefully read the medical records;the wrong coding classified the congenital ptosis as the congenital ptosis;80 cases had the wrong operation coding,with the error rate of 22.7%,of which 80 cases had the clear operation type on the first page of doctors The error rate was 0.05%.In 272 cases,the operation type was not defined on the first page of the doctor,76 cases were coded incorrectly by the coder,and the error rate was 27.9%.Conclusion Congenital blepharoptosis is a congenital disease,which does not belong to the payment scope of the medical insurance co-ordination fund.Therefore,in order to avoid this kind of problem,the clinician mainly does not make clear whether the diagnosis of blepharoptosis is congenital or acquired,the coder does not read the medical record carefully,and the false is the direct input of postnatal nature,resulting in the wrong diagnosis code;because of the causes of blepharoptosis and The specific conditions are different,so there is no one operation can be applied to all the correction of ptosis.If the doctor does not clearly write out the operation method,then the coder needs to understand the clinical knowledge and operation steps,communicate with the clinician in time,and accurately code.