肠梗阻相关编码质量分析

Analysis of Coding Errors Related to Intestinal Obstruction

目的分析某三甲医院主要诊断为各类肠梗阻病例的编码错误情况,以提高肠梗阻ICD-10编码的准确性。方法对某三甲教学医院急诊外科出院时间2018年1月1日-2019年12月31日,主要诊断为肠梗阻的638份病案,按照国际疾病分类原则和主要诊断选择原则,查找各类肠梗阻的编码情况,总结肠梗阻编码错误类型。结果编码为K56.7未特指的肠梗阻病例数336例,结果发现其中105例肠梗阻诊断编码存在错误,错误率为31.3%,手术后肠梗阻编码错误率最高为20.54%,其次为肿瘤占4.76%、疝伴梗阻占2.98%。结论引起肠梗阻的病因很多,造成肠梗阻ICD-10编码多样化,编码人员应该了解ICD-10第一卷中肠梗阻编码的包括与不包括情况,掌握各类肠梗阻编码知识,进一步认识肠梗阻的病因,仔细阅读病案,提高编码准确率。

Objective To analyze the coding errors of various types of intestinal obstruction diagnosed in a Three A and Tertiary Hospital in order to improve the accuracy of ICD-10 coding of intestinal obstruction.Methods According to the medical records of various types of intestinal obstruction diagnosed in the emergency department of a tertiary teaching hospital from January 1,2018 to December 31,2019,according to the principles of international disease classification and main diagnosis selection principles,search for various types of intestinal obstruction Coding situation,type of coding error for total colonic obstruction.A total of 636 cases mainly diagnosed as various types of intestinal obstruction were searched.Results 336 cases were coded as K56.700 unspecified intestinal obstruction.By viewing the original medical record data,combining the medical record homepage,admission record,disease course record,discharge record,operation record,abdominal CT,abdominal ultrasound and other examination results,it was found that 105 cases of intestinal obstruction had errors in the diagnosis code,with an error rate of 31.3%.Among them,postoperative intestinal obstruction had the highest coding error rate of 20.54%,followed by tumor(4.76%)and hernia with obstruction(2.98%).Conclusions There were many causes of intestinal obstruction,and the ICD-10 codes of intestinal obstruction were diversified.Coders should understand the intestinal obstruction codes including and not including conditions,master various types of intestinal obstruction codes,and further understand the different causes of intestinal obstruction in clinical diagnosis.Read medical records to improve coding accuracy.