ICD-10中R编码应用案例分析

Application case analysis of R coding in ICD-10

目的对某医院主要诊断编码为R编码的疾病编码质量进行审查,总结错误类型并选出典型案例分析讨论,为提高疾病编码准确率、顺利开展按DRGs付费工作提供保障。方法提取2021年10月1日至12月31日,出院病案中主要编码为R编码的病案437例,运用国际疾病分类规则逐份查阅病案、审核编码。结果主要编码为R编码的437例病案中,编码错误51例,错误率11.7%。错误病案按错误类型分为4类,其中应分类至其他章占58.8%(30/51)、主要编码选择错误占31.4%(16/51)、漏编码病因或主要治疗情况占7.8%(4/51)、其他错误占2.0%(1/51)。结论编码员未认真查阅病案、盲目遵从医师选择主要编码、欠缺医学知识及分类规则知识是导致某院R编码错误的主要原因。为提高编码质量,编码员需提高业务知识水平并加强编码质控工作。

Objective To review the quality of disease coding with R code as the main diagnostic code in a hospital,summarize the error types,and select typical cases for analysis and discussion,in order to provide guarantee for improving the accuracy of disease coding and carrying out DRGs payment smoothly.Methods Four hundred and thirty-seven medical records with R code of discharged patients from October 1,2021 to December 31,2021 were extracted,and the medical records were consulted and reviewed one by one according to the international classification of diseases.Results There were 51 coding errors with an error rate of 11.7%among the 51 cases with R coding.The erroneous medical records were divided into 4 categories according to the error type,among which 58.8%(30/51)should be classified to other chapters,31.4%(16/51)were wrong in the selection of major codes,7.8%(4/51)missed the coding of disease cause or main treatment(4/51),and other errors accounted for 2.0%(1/51).Conclusion The main causes of R coding errors in the hospital are coders′failure to consult medical records,blind compliance with doctors′choice of main codes,and lack of medical knowledge and classification rules.In order to improve coding quality,coders need to improve their professional knowledge and strengthen coding quality control.