康复医学科常见主要诊断编码错误案例分析

Analysis of Common Main Diagnostic Coding Errors in Rehabilitation Medicine Department

分析康复医学科5个常见疾病主要诊断编码错误案例:错误使用偏瘫(G81.900)作为患者从神经内科治疗脑梗死后转科至康复科康复治疗出院后的主要诊断,错误使用康复医疗(Z50.900x001)作为患者从脊柱外科手术治疗后转科至康复科康复治疗后出院的主要诊断,错误使用脑出血后遗症(I69.100x001)作为患者术后出院再入康复科康复治疗后的主要诊断,错误使用椎管狭窄(M48.000)统计码作为主要诊断编码,错误使用脑梗死(I63.900)未特指编码作为主要诊断编码。正确的主要诊断及其编码是大脑动脉闭塞脑梗死I63.502、颈部脊髓损伤S14.101、偏瘫G81.900后遗症编码为脑出血后遗症I69.100x001可作为附加编码、腰椎椎管狭窄M48.005、颈动脉闭塞脑梗死I63.204;影响康复医学科主要诊断编码错误的原因包括未正确掌握主要诊断选择的原则、统计码和未特指编码的使用规则等,需引起临床医师和编码员的高度重视。

This study aims to analyze five common main diagnostic coding error cases in the rehabilitation medicine department: Hemiplegia(G81.900) was mistakenly used as the major diagnosis after the cerebral infarction patient was transferred from neurology department to rehabilitation department for rehabilitation treatment and was discharged;Rehabilitation medical treatment(Z50.900x001) was mistakenly used as the main diagnosis after the surgical patient was transferred from spinal surgery department to rehabilitation department for rehabilitation treatment and was discharged;Sequelae of intracerebral hemorrhage(I69.100x001) was mistakenly used as the main diagnosis of the patient who was discharged after surgery and re-admitted to the rehabilitation department for rehabilitation treatment;The statistical code of spinal stenosis(M48.000) was mistakenly used as the main diagnostic code;Not otherwise specified(NOS)code of cerebral infarction(I63.900) was mistakenly used as the main diagnostic code, and the correct main diagnostic code after quality control was given. This study clarified the causes leading to the diagnostic coding error in rehabilitation medicine, which included incorrectly mastering of the principles of main diagnostic selection and the usage rules of statistical code and NOS codes, and clinicians and coders need to pay close attention to them.