流产结局ICD编码实例探讨

Discussion on ICD Coding of Examples of Abortion Outcome

流产是孕妇入住产科的常见原因,妊娠满28周及以上的流产病例ICD编码极易与分娩结局相关编码混淆。实际工作中常用的流产结局诊断编码包括O00-O04以及O08,入院流产者应根据具体情况选择异常妊娠、自然流产或医疗性流产本身、不宜继续妊娠的胎儿或母体因素为主要诊断编码;合并流产并发症者应当使用O03-O07的亚目以及O08加以说明;流产完全与否应当使用O03-O06共用亚目加以明确。结合典型案例,列举流产结局常用手术操作编码。产科病案编码员应当具备良好的产科知识储备和编码业务水平,编码流产结局病案时需认真通读病案,加强与临床医师及编码同行的沟通交流,从而持续改进流产结局病案编码质量。

Miscarriage is a common reason for pregnant women to be admitted to the obstetrics department. The ICD codes of abortion medical records of pregnancy up to or over 28 weeks can easily be confused with codes related to delivery outcomes. Commonly used diagnostic codes for miscarriage outcome in real work include O00-O04 and O08. In this article, based on typical cases, it is believed that cases which patients are admitted to hospital for abortion should choose abnormal pregnancy, spontaneous abortion or medical abortion themselves, and fetuses or maternal factors that are not suitable for continuing pregnancy as the main diagnostic codes according to the actual condition. Those cases with complications of miscarriage should use the O03-O07 suborder and O08 to explain,whether the abortion is complete or not should be clarified by using the O03-O06 shared suborder. In addition, the codes of commonly used surgical operations in cases of abortion outcomes are listed. Obstetric medical record coders should have good obstetric knowledge and coding skills. When coding abortion outcome medical records, they need to carefully read through the medical records, maintain communication with clinicians and coding colleagues, so as to continuously improve the quality of abortion outcome medical records coding.