唐氏综合征产前筛查及产前诊断ICD-10编码案例分析

Case Analysis of ICD-10 Coding for Prenatal Screening and Prenatal Diagnosis of Down Syndrome

唐氏综合征又称为21-三体综合征,是新生儿最为严重的先天缺陷之一,主要特征为严重的先天智力障碍,特殊面容,并常伴有各种先天畸形。对于在产前行唐氏综合征筛查的病例,归类于Z36的编码;经产前筛查后,如提示胎儿罹患唐氏综合征高风险,归类于O28.0或O28.5的编码;如经产前诊断确诊胎儿罹患唐氏综合征,归类于O35.1的编码,若发现胎儿染色体异常来源于其母亲时,应使用附加编码O99.8和Q90-Q99描述其母亲染色体异常的具体情况;如需终止妊娠,归类于O04和O35.1的编码。本文还对一例进行了基因检测的案例进行编码分析,探讨该疾病的ICD-10编码难点及编码思路,当流产结局(O00-O08)和流产病因同时出现在诊断中,应选择结局(O00-O08)作为主要诊断编码。实践证明,编码员除了要熟练的掌握ICD-10编码原则外,还应掌握一定的临床医学知识,做到充分了解所编码的疾病,并在日常工作中多研读病历,才能准确的进行编码。

Down syndrome,also known as trisomy 21 syndrome,is one of the most serious congenital defects in newborns,which is mainly characterized by severe congenital mental retardation,special face,and often accompanied by various congenital malformations.For the cases who were screened for Down syndrome before delivery,they were classified as the code of Z36.After prenatal screening,if the fetus was at high risk of Down syndrome,it was classified as the code of O28.0 or O28.5.If the fetus suffering from Down syndrome is diagnosed by prenatal diagnosis,it is classified into the O35.1 code.If it is found that the fetal chromosome abnormality comes from the mother,the additional codes O99.8 and Q90-Q99 should be used to describe the maternal chromosome abnormality,and if the pregnancy needs to be terminated,it should be classified into the O04 and O35.1 codes.This paper also makes a coding analysis of a case of gene detection,and discusses the difficulties and ideas of ICD-10 coding of the disease.When the abortion outcome(O00-O08) and the cause of abortion appear in the diagnosis at the same time,the outcome(O00-O08) should be selected as the main diagnostic code.Practice has proved that coders should not only skillfully master ICD-10 coding principles,but also master certain clinical medical knowledge,fully understand the encoded diseases,and study more medical records in their daily work in order to code accurately.