常见易混淆子宫疾病编码分析

An analysis of the ICD coding of confusable diseases of uterus

目的 对临床诊断为子宫内膜异位,子宫肌瘤,子宫内膜间质异位,子宫内膜增生等疾病准确编码。方法讨论易混淆疾病的诊断名称及别称,病理表现及相应的ICD编码。结果 子宫腺肌瘤(N80. 0)与子宫腺肌瘤(D26.1)属于两种不同的疾病,疾病编码中应重点区分,前者分类于子宫内膜异位性疾病中,后者分类于子宫的良性肿瘤。子宫内膜异位(N80. 0),是指子宫的子宫内膜异位,而子宫内膜异位症(N80. 9),是指未特指部位的子宫内膜异位,应注意根据异位部位具体编码。间质性子宫内膜异位不应归类于N80,ICD第二版中归类于D39. 0(M8930/1),现ICD-O已更新于M8930/3。结论 编码过程中应仔细阅读病案,对于易混淆疾病,应区分疾病性质,临床表现及分型,应格外注意临床诊断名称的相似性及诊断的别称,根据ICD疾病编码的分类轴心,正确编码。

Objective To explore the coding method and improve the accuracy of endometriosis.Methods To analyze the clinical manifestations,pathology and ICD coding of adenomyoma and its easily confused diseases,adenomyosis,adenomyosis,Uterine myoma,fibrioid and endometrial hyperplasia.Results Adenomyoma(N80.0)and Uterine myoma,fibrioid(D26.1)belong to two different diseases,which should be distinguished in ICD.The former is classified in endometriosis,and the latter is classified in benign uterine tumors.Endometriosis of uterus(N80.0)refers to the endometriosis of the uterus.Endometriosis(N80.9)refers to the endometriosis of the unspecified site,which should be coded according to the ectopic site.The code of ICD-10 for endometrial stromal nodule(ESN)is D39.0(M8930/1)and ICD-O is M8930/3.Conclusion Medical records should be carefully read in the coding process.For confusing diseases,the nature of the disease,clinical manifestations and classification should be distinguished.Special attention should be paid to the similarity of clinical diagnosis names and the other names of diagnoses.Correct coding should be carried out according to the classification axis of ICD disease coding.