眼科手术易错的编码分析

Coding Analysis of Eye Surgery Error-Prone

目的分析某三级综合医院眼科住院病案首页手术操作情况,提高眼科手术编码质量。方法利用病案管理检索系统提取某三级综合医院2019年1月1日至2019年12月31日眼科进行手术治疗的住院病案信息,随机抽取500份眼科住院病案,根据ICD-9-CM-3原则,通过核查病案内容对其手术编码进行重新审核,统计手术编码错误例数与总例数的比值,计算手术编码错误率,分析手术编码错误情况。结果500份眼科手术病案中有281份手术编码错误,错误率达到56%。其中翼状胬肉切除术错误率为75%;眼球内容物剜除伴义眼台置入术错误率为60%;小梁切除术错误率为58%;睑内(外)翻+睑重建术错误率为52%;白内障超声乳化术错误率为48%;眼睑板腺囊肿切除术错误率为44%。结论眼科手术编码较为复杂,容易编错,编码员应熟练掌握编码规则,了解临床知识,临床医师应规范书写病历,科室应建立有效的编码质控体系,才能提高眼科手术编码质量。

Objective To improve the coding quality of ophthalmic surgery by analyzing the operating conditions of the first page of the ophthalmic inpatient in a tertiary general hospital.Methods The medical record management retrieval system was used to extract the information of hospitalized medical records of ophthalmology surgery in a third-level general hospital from January 1,2019 to December 31,2019.500 ophthalmic hospitalized medical records were randomly selected.According to the ICD-9-CM-3 principle,the operation code was re-examined by checking the contents of medical records,the ratio of surgical coding errors to the total number of surgical coding errors was calculated,and the surgical coding error rate was calculated.The error of surgical code was analyzed.Results Out of 500 medical records of ophthalmic surgery,281 surgeries were coded incorrectly,with an error rata of 56%.The error rate of pterygium excision was 75%.The error rate of enucleation of eyeball contents with implantation of prosthetic platform was 60%.The error rate of trabeculectomy was 58%.The error rata of eyelid internal turning+eyelid reconstruction was 52%.The error rate of phacoemulsification for cataract was 48%.The error rate of eyelid plate adenocyst resection was 44%.Conclusion The coding of ophthalmic surgery surgery is complex and easy to be miscoded.coders should master the coding rules and understand clinical knowledge,clinicians should standardize the writing of medical records,and departments should establish effective coding quality control system to improve the coding quality of ophthalmic surgery.