关于半月板损伤的疾病和手术编码探讨

Code Analysis of Meniscus Injury Diseases and the Relevant Surgical Operations

通过了解半月板损伤的病因和治疗方式,结合相关病例探讨半月板损伤的疾病编码和手术操作编码。对于半月板损伤的病案,首先需要详细阅读病案分析其损伤的原因,一般情况下半月板损伤分为外伤性和自身退变性,且外伤性损伤需要根据受伤的时间进行区分。3周以内的创伤性半月板损伤编码S83.2,3周以上陈旧性创伤性半月板损伤编码M23.2,非创伤性半月板损伤编码M23.3。根据手术记录明确手术的入路和具体术式,膝半月软骨切除术80.6,膝关节三联修补术81.43,膝五合一修补术81.42,膝关节的其他修补术81.47,关节病损的其他局部切除术或破坏术80.8,滑膜切除术80.7,其他关节切开术80.1,关节镜检查80.2。编码需注意损伤性质、损伤时间及手术入路与具体术式,要求临床医师提高书写质量与病案完整性;编码员不断加强临床医学知识,仔细阅读病案,加强与临床医师的沟通以期提高编码质量。

The Meniscus injury is one of the common orthopedic problems in the clinical medicine.Based on the main causes of the disease,the case studies andliterature review,this paper summarizes the approach and the operating procedure of coding the Meniscus injury diseases and the relevant operations.To encode the types of the injury,the initial step is toanalyze the main reasons of causing Meniscus injury,which is generally divided intoTraumatic injury and Self-degeneration.And Traumatic injury should further be sorted according to the period of injury.For disease code,Tear of meniscus,current(S83.2) should be encoded in cases of patients whose injury periodsareshorter than 3 weeks.If the period is more than 3 weeks,coders could encode Derangement of meniscus due to old tear or injury(M23.2)instead of other meniscus derangements(M23.3).For the surgical coding,the key lies in the surgical approaches andthe specific surgical optionsin surgery operative logs:Excision of semilunar cartilage of knee,coding 80.6;Triad knee repair is classified as 81.43;Five-in-one repair of knee is classified as 81.42;Other repair of knee is classified as 81.47;Other local excision or destruction of lesion of joint is classified as 80.8;Synovectomyis classified as 80.7;Other arthrotomyis classified as 80.1 and Arthroscopy categories 80.2.Coding should be involved in the character and time of the injury as well as the approach and form of the operation.Clinicians are required to improve the writing quality and the completeness of medical records.In order to obtain better coding quality,coders should continue to enhance the knowledge of clinical medicine and read the medical records carefully while strengthening communication with the clinicians.