225例耳部肿瘤编码错误分析

Analysis of Coding Errors in 225 Cases of Ear Tumors

目的 通过核查某院近4年耳部肿瘤诊断的ICD编码,分析编码错误原因,提高编码正确率。方法 利用病案统计系统调取某院2018年1月1日-2021年12月31日诊断为耳部肿瘤的病例共计225例,进行回顾性分析。利用编码工具书,按照肿瘤的编码查找方法,分别对肿瘤的形态学编码和部位编码进行核查。对错误的编码进行分析。应用描述性统计方法分析编码错误的原因。结果 耳科肿瘤形态学编码错误55例,错误率最高是皮样囊肿37例,占比67.3%,其次是乳头状瘤15例,占比27.3%,血管瘤、乳头状囊腺瘤、鳞状细胞癌的错误率为1例,占比1.8%;部位编码错误72例,错误最多的是外耳(耳廓和外耳道)良性肿瘤66例,占比91.7%,耳部结缔组织良性肿瘤4例,占比5.6%,耳部结缔组织恶性肿瘤2例,占比2.8%。结论 耳部肿瘤编码具有复杂性,编码员需要提高自身医学知识储备,熟练掌握编码规则,才能准确编码。

Objectives To analyze the causes of coding errors and improve the coding accuracy by checking the ICD codes of ear tumor diagnosis in a hospital in recent 4 years.Methods A total of 225 cases of ear tumors diagnosed in a hospital from January 1 st,2018 to December 31 st,2021 were retrospectively analyzed by medical record statistics system.Using coding reference book,according to the method of searching tumor code,the morphological code and site code of tumor were checked respectively,and analyzed the wrong encoding.Descriptive statistics were used to analyze the causes of coding errors.Results There were 55 cases of morphological coding errors in ear tumors,the highest error rate was dermoid cyst in 37 cases(67.3%),followed by papilloma in 15 cases(27.3%),hemangioma,papillary cystadenoma and squamous cell carcinoma in 1 case(1.8%).There were 72 cases of coding errors,most of which were benign tumors of external ear(auricle and auditory canal) in 66 cases(91.7%),benign tumors of connective tissue in 4 cases(5.6%) and malignant tumors of connective tissue in 2 cases(2.8%).Conclusions Ear tumor coding was complicated,coders needed to improve their own medical knowledge reserve and master the coding rules to accurately code.