分娩过程中常见手术操作分类编码探讨

Discussion on the Classification and Coding of Common Surgical Procedures during Delivery

分娩过程中常见手术操作主要涉及助产性手术操作和产伤性清除、修补手术。助产性手术操作主要包括会阴侧切缝合术不伴产钳编码于73.6和伴产钳编码于72.1-72.3;产程开始前人工破膜术编码于73.01和产程开始后编码于73.09。产伤性清除、修补手术主要包括血肿清除术编码于75.91-75.92,产科近期裂伤修补术子宫部位的编码于75.50-75.52和其他部位的编码于75.61、75.62、75.69。本文在分析分娩常见手术操作方式适应症的基础上,探讨其编码及查找方法,通过剖析具体案例,总结其编码易错点在于编码员对分娩手术操作分类轴心缺乏明确认识,临床医师书写手术名称较为简略,编码员过分依赖编码库。编码员需注意区分不同分娩手术操作目的和方法,了解手术操作编码规则,认真阅读病案,才能提高编码准确性。

The common operation in the process of delivery mainly involves the operation of midwifery and the operation of removal and repair of birth injury. Midwifery surgical procedures mainly included perineal resection and suturing without forceps(code 73.6) and forceps(code 72.1 to 72.3). Manual rupture of the membrane was coded at 73.01 before labor and 73.09 after labor. Obstetric injury removal and repair operations mainly included hematoma removal in 75.91-75.92, recent obstetric laceration repair in uterine site in 75.50-75.52 and other sites in 75.61, 75.62, 75.69. In this paper, based on the analysis of the indications of common operation methods in childbirth, the coding and search methods are discussed. Through the analysis of specific cases, it is concluded that the coding error lies in the coders’ lack of clear understanding of the axis of classification of operation in childbirth,the clinicians’ brief writing of operation names, and the coders’ excessive reliance on code base. Coders should pay attention to distinguish different purposes and methods of delivery operation, understand the coding rules of operation, and read medical records carefully to improve the accuracy of coding.