242份肺结节胸腔镜手术编码错误分析与改进思路

Analysis and Improvement of Coding Errors in 242 Thoracoscopic cases of Pulmonary Nodules

目的 分析影像学诊断肺结节后行胸腔镜手术治疗的住院病案首页编码质量,探讨改进思路。方法 以住院病案首页中主要手术编码类目32.为检索条件,调取某院胸外科2020年1月1日-2020年12月31日影像学诊断肺结节后行胸腔镜手术治疗的242份病案,由1名编码质控员、1名病理科质控员和1名临床医师共同完成住院病案首页审核,对手术编码正确情况进行审核。结果 242份住院病案首页中85份出现编码错误,错误率为35.12%,错误共103项,其中,疾病分类错误20项,占19.42%,主要集中在病理报告为结节状淋巴组织增生、结节软骨样错构瘤错误分类至D14.300x001肺良性肿瘤;病理形态学编码错误83项,占比80.58%,错误主要集中在贴壁型为主的浸润性腺癌应分类至M8250/3,笼统分类至M81400/3腺癌NOS;非典型腺瘤样增生和硬化性肺泡细胞瘤错误分类于M80000/0良性肿瘤。结论 提高住院病案首页的病理形态学编码及主要诊断编码准确率,需要编码员不断加强ICD专业知识及相关临床知识的学习,通过思维导图整理常见形态学编码、参与病理讨论会,强化有效沟通,使临床、病理、编码三方的知识互相渗透,是提高肺结节胸腔镜手术住院病案首页质量的重要途径。

Objectives To analyze the coding quality of the front page of inpatient medical records after thoracoscopic surgery after imaging diagnosis of pulmonary nodules,and explore the improvement ideas.Methods The main operation code category 32 in the front page of inpatient medical records was used as the retrieval condition.A total of 242 medical records of video-assisted thoracoscopic surgical treatment after imaging diagnosis of pulmonary nodules were collected from the department of thoracic surgery of a hospital from January 1 st,2020 to December 31 st,2020.A coding quality controller,a quality controller from the department of pathology and a clinician jointly completed the front page review of inpatient medical records to verify the correctness of surgical coding.Results In the front page of 242 inpatient medical records,85 of them had coding errors,with an error rate of 35.12%.There were 103 errors in total,among which 20 were disease classification errors,accounting for 19.42%,mainly focusing on the pathological reports of nodular lymphoid hyperplasia and nodular chondroid hamartoma misclassified to D14.300x001 benign lung tumor.There were 83 pathologic coding errors,accounting for 80.58%.The errors were mainly concentrated in the classification of invasive adenocarcinoma as M8250/3 and adenocarcinoma as M81400/3 NOS.Atypical adenomatous hyperplasia and sclerosing alveolar cell tumors were misclassified as M80000/0 benign tumors.Conclusions To improve the pathological morphology of the hospital medical record front page code and main diagnostic accuracy,coding coders need to continue to strengthen the ICD professional knowledge and related clinical knowledge learning,common morphology coding by mind map processing,participate in pathological conference,to strengthen the effective communication,make the clinical,pathological and coding knowledge of three parties,mutual penetration.It was an important way to improve the quality of the front page of inpatient medical record of thoracoscopic operation for pulmonary nodules.