浅析综合征的编码思路

A Brief Analysis of the Coding Ideas of Syndrome

综合征通常是一组症状和体征,以联合的形式出现,很多综合征在ICD-10中没有一个单一准确的编码,编码时要根据其临床表现或病因进行编码。因综合征涉及的临床知识较为复杂,其编码一直是ICD编码工作的难点。编码员不仅需要综合运用编码技能,还需要分析疾病的内涵,才能给出一个合适的编码。通过案例分析林奇综合征、直肠前切除综合征和复杂性区域疼痛综合征3例综合征的编码思路,并分别给予ICD-10编码为Z80.0肿瘤家族史,K91.824手术后肛门括约肌失禁、M89.003交感神经反射性营养不良。提升编码员的编码能力和建立编码讨论制度,进而提高疑难编码的准确性和科学性。

Syndrome is usually a group of symptoms and signs,in the form of a combination,many of the syndrome in ICD-10 there is no a single accurate code,when coding according to its clinical manifestations or etiology.Because of the complexity of clinical knowledge involved in"syndrome",its coding has been a difficult task in ICD coding.It is necessary not only to use the coding skills,but also to analyze the meaning of disease in order to give a proper coding.In this paper,we analyzed the coding ideas of Lynch Syndrome,Anterior rectotomy syndrome and Complex regional pain syndrome,and gave ICD-10 code as Z80.0 cancer family history,K91.824 Postoperative anal sphincter incontinence,and M89.003 Sympathetic reflex dystrophy.This paper further discusses how to improve the accuracy and scientificity of difficult coding by improving the coding ability of coders and establishing the coding discussion system.