医疗行为影响产科编码实例

Case Analysis on the Influence of Medical Treatment on ICD-10 Code on Obstetric Department

由于产科学是一门研究女性妊娠期、分娩期及产褥期全过程的学科,产科诊断不单纯是疾病诊断,还包括孕产妇及胎儿生理情况及医疗行为的内容,编码员在分类产科诊断时需注意医疗行为对产科编码的影响。本文根据医疗行为对产科ICD-10编码的影响,提出类目O32-O36编码的使用需结合医疗行为实施的与否进行分类,对于未给予孕产妇医疗的情况不可分类至O32-O36;根据医疗行实施的对象,区分孕妇体内的胎儿及脱离母体后的新生儿诊断编码;根据医疗行为实施的内容确定分娩方式编码,判断是否使用梗阻性分娩的编码。并以实例分析忽略医疗行为对产科ICD-10编码的影响造成错误编码的情况。提出编码员应熟悉产科学的临床知识,以便于理解产科诊断分类原则并根据具体医疗行为进行编码,提高产科ICD-10编码的正确率。

Because obstetrics is a subject that studies the whole process of pregnancy, delivery and puerperium, obstetric diagnosis not only is disease diagnosis, but also includes maternal and fetal physiological information and the records of medical treatment. Coders should pay attention to the influence of medical treatment on obstetric ICD-10 coding when classifying obstetric diagnosis. According to the influence of the medical treatment on the obstetric ICD-10 code, this paper suggests that the use of codes O32-O36 needs to be based on whether a medical treatment is performed, and cases without medical treatment for pregnant women cannot be classified to codes O32-O36. Codes are distinguished between the fetus in the pregnant woman and the newborn after separation basing on the objects that receive medical treatment. The delivery mode code and the obstructed labor code are used basing on the content of the medical treatment. Moreover, this paper used actual cases with coding errors to analyze the impact of neglecting medical treatment on obstetrical ICD-10 coding and suggests that coders should be familiar with clinical knowledge of obstetrics in order to understand the principles of obstetric diagnostic classification and improve the accuracy of icD-10 coding according to specific medical treatments.