急性肾损伤ICD-10编码质量分析

Analysis of ICD-10 Code Quality of Acute Kidney Injury

目的通过分析急性肾损伤疾病编码错误原因,探讨不同类型急性肾损伤编码,提高编码的准确率。方法检索某医院2018年1月1日至2020年12月31日出院患者中诊断为急性肾损伤的病案128份,出院诊断编码为N17急性肾衰竭、N19未特指的肾衰竭、S37.0肾损伤的病案首页,包括主要诊断和其他诊断。归纳不同类型急性肾损伤对应的ICD-10编码,检查疾病编码的准确性,并对疾病编码错误原因进行分析。结果128份住院病案首页中出院诊断疾病编码共有76例错误,编码错误率占59.37%,错误内容分为2大类,第1类主要诊断编码错误,占比34.21%,第2类其它诊断编码错误,占比65.79%。错误最多编码为未特指的急性肾衰竭46份,占60.53%;未给予双重分类编码10份,占13.16%;未按照疾病病因和解剖部位编码9份,占11.84%;诊断分开填写或诊断不完整8份,占10.53%,各种类型急性肾损伤编码错误的原因主要在于编码员专科知识欠缺及国际疾病分类编码规则认识不足,住院医师诊断书写不规范,缺乏病案编码质量管理。结论急性肾损伤疾病编码错误率较高,编码人员需不断学习急性肾损伤相关医学知识,与临床医师充分有效沟通,并将编码质控作为长效机制,不断提高急性肾损伤编码的准确性。

Objectives By analyzing the current status of acute kidney injury coding and the reasons for incorrect coding,explore different types of acute kidney injury coding and improve the accuracy of coding.Methods A total of 128 medical records of patients discharged from a hospital between January 1st,2018 and December 31st,2020 with discharge diagnosis code N17 acute renal failure,N19 unspecified renal failure,and S37.0 renal injury were retrieved,including the primary diagnosis and other diagnoses.ICD-10 codes corresponding to different types of acute kidney injury were summarized,the accuracy of disease codes was checked,and the causes of disease coding errors were analyzed.Results In the front page of 128 inpatient medical records,there were 76 errors in the disease codes for discharge diagnosis,accounting for 59.37%.The errors were divided into two categories:the first category was mainly diagnostic coding errors,accounting for 34.21%,and the second category was other diagnostic coding errors,accounting for 65.79%.The highest number of errors was unspecified acute renal failure(46),accounting for 60.53%.10 were not given double classification code,accounting for 13.16%;9(11.84%)were not coded according to disease etiology and anatomical location;Eight diagnoses were filled out separately or were incomplete,accounting for 10.53%.The coding errors of various types of acute kidney injury were mainly caused by the lack of specialized knowledge of coders and the lack of understanding of the coding rules of the International Classification of Diseases,non-standard writing of the diagnosis of resident doctors,and the lack of quality management of medical record coding.Conclusions The coding error rate of acute renal injury disease was high,Coding personnel needed to constantly learn clinical knowledge,fully and effectively communicate with clinicians,and take coding quality control as a long-term mechanism,so as to continuously improve the accuracy of disease coding.