癫痫ICD-10编码质量分析

Quality Analysis of ICD-10 Coding for Epilepsy

目的 分析住院病案首页中癫痫编码现状,提出相应措施提升编码质量。方法 在某三级医院住院病案首页管理系统中以主要诊断编码包含癫痫G40和癫痫持续状态G41为检索条件,筛选2020年1月1日至2020年12月31日神经内、外科出院病案,由神经科医师参考临床诊疗指南癫痫分册及2017版国际抗癫痫联盟(International League Against Epilepsy,ILAE)癫痫分类作为癫痫诊断和分类的标准,与资深编码员共同对编码进行核查,回顾性分析癫痫编码情况。结果 审核的456份癫痫病案中,错误编码共计131份,错误率为28.73%。其中19份类目编码错误,错误率为4.17%;112份亚目编码错误,错误率为24.56%。残余类目G40.9的错误构成比最高。总结存在的编码缺陷类型为主要诊断选择错误、癫痫类型编码错误以及存在大量残余类目编码。结论 癫痫类目编码错误率不高,但亚目编码错误率较高,主要由于编码员对临床的癫痫类型分类不够了解。加强编码员临床知识的培训,规范临床医师的诊断书写习惯,借助结构化的电子病历诊断模板,以提高编码质量。

Objective Analyzes the current situation of epilepsy coding in the first page of hospitalized medical records,and puts forward corresponding measures to improve the coding quality.Methods Data were collected from the hospital information management system with principle diagnosis codes including G40 and G41 discharged from neurology department from January 1,2020 to December 31,2020.Clinical documentation was reviewed by a group of neurologists to identify the epilepsy cases based on the clinical guideline and ILAE classification,and codes were assessed with an experienced clinical coder.Results A total of 456 cases were included with 131 cases coded inaccurate,the error rate was 28.73%.Among these cases,19 cases were coded to inaccurate category,error rate was 4.17%.112 cases were coded to inaccurate subcategory,error rate was 24.56%.The error constituent ratio of residual category G40.9 is the highest.The main error types were inaccurate principle diagnosis code,inaccurate subcategory code and large number of unspecified code.Conclusion High inaccurate subcategory rate indicates a lack of clinical knowledge of epilepsy classification.Enhance coders’ clinical knowledge,standardized clinicians’ writing patten and use of a structured diagnostic template to improve coding quality.