中耳和内耳常见手术ICD-9-CM-3编码分析

ICD-9-CM-3 coding analysis of common middle and inner ear surgeries

目的对常见中耳及内耳术手术编码中存在的问题进行分析探讨。方法首先,本研究回顾不同的中耳和内耳手术方式相关医学知识。然后,利用国际疾病分类第九版临床修订本手术与操作ICD-9-CM-3工具书,总结常用手术的查找路径,确定相应的编码。最后,依据ICD-9-CM-3中耳和内耳手术19.0-20.9编码原则,通过案例分析探讨临床常用手术编码,并对其中出现的错误进行分析总结。结果在编码过程中,中耳手术(包括鼓室成形术、听骨链重建术和乳突改良根治术等)和内耳手术(包括半规管阻塞术、内淋巴囊手术和迷路切除术等)容易误编,其附加手术如:外耳道成形术、耳甲腔成形术、上鼓室鼓窦切开术、半规管开窗术、镫骨撼动术等容易漏编、重复编码甚至多编。结论为了提高编码的准确性,编码员务必结合编码分类原则和临床相关知识,仔细阅读病案相关记录进行手术编码。有必要采取相应措施规范临床医师手术记录和手术名称的书写,开展病案首页编码质控,规避手术编码错误问题。

Objective To analyze the encountered problems in the coding of common middle and inner ear operations.Methods First,the study reviewed the medical knowledge related to different middle ear and inner ear surgical modalities.Then,using the International Classification of Diseases Clinical Modification of 9th Revision Operations and Procedures ICD-9-CM-3 reference book,it summarized the search paths of common surgeries,and determined the corresponding codes.Finally,according to the coding principles of ICD-9-CM-3 middle ear and inner ear surgery 19.0-20.9,the common clinical surgical coding was discussed through case analysis,and the errors that occur in it were analyzed and summarized.Results In the coding process,coders were prone to miscoding of middle ear operations(including tympanoplasty,ossicular chain reconstruction,modified radical mastoidectomy,etc.)and inner ear operations(including semicircular canal occlusion,endolymphatic sac surgery and labyrinthectomy,etc.).And their additional operations such as reconstruction of external auditory canal,cavoplasty,atticoantrostomy,semicircular canal fenestration,and stapes mobilization,were easy to miss coding,repeat coding or even multiply coding.Conclusions In order to improve the accuracy of coding,coders should combine coding classification principles with clinical relevant knowledge,and carefully read the relevant medical record to classify and code.It is necessary to take corresponding measures to standardize the writing of clinicians’surgical records and surgical names,and to carry out coding quality control on the first page of medical records to avoid errors in surgical coding.