皮肤恶性肿瘤手术ICD编码及对患者住院的影响分析

Analysis of ICD codes for Skin Malignant Tumor Surgery and Influence on Patients'Hospitalization

目的分析皮肤恶性肿瘤手术病人ICD编码错误情况及不同部位皮肤恶性肿瘤的住院天数和住院费用,探讨部位编码的重要性,以引起对编码准确性的重视。方法从某三级甲等肿瘤专科医院病案管理系统中检索2018年1月1日-2020年12月31日主诊断编码为C44、C60.901和C63.201的病案,依据国际疾病分类ICD-10和手术与操作ICD-9-CM-3的分类原则,对546例病案中的疾病诊断编码和手术操作编码进行分析。结果546例病案中诊断编码不准确的占16.85%,手术编码分类不准确的占22.53%。不同部位皮肤恶性肿瘤的患者住院天数和住院费用差异有统计学意义。结论皮肤恶性肿瘤手术病案编码错误较多,数据质量可能会影响进一步的病案数据利用。

Objective To analyze the ICD coding errors of patients undergoing skin malignant tumor surgery and the inpatient days and hospitalization expenses of different located skin malignant tumors;To explore the importance of location coding to attract attention to the accuracy of coding.Methods The medical records with the main diagnosis codes C44,C60.901 and C63.201 from January 1,2018 to December 31,2020 were retrieved from the medical record management system of a grade-A tertiary cancer hospital.According to the International Classification of Diseases ICD-10 and the classification principle of surgery and operation ICD-9-CM-3,the disease diagnosis codes and operation codes in 546 medical records were analyzed.Results Of the 546 medical records,16.85% had inaccurate diagnostic codes,and 22.53% had inaccurate surgical codes.There were statistically significant differences in the inpatient days and hospitalization expenses of patients with skin malignant tumors at different locations.Conclusion There are many coding errors in the surgical records of skin malignant tumors,and the data quality may affect the further use of medical record data.