纵隔肿瘤ICD-10编码分析

Analysis of ICD-10 coding for mediastinal tumors

目的分析某三甲肿瘤专科医院纵隔肿瘤错误编码的案例,提高临床医师首页填写质量的意识,规范医师填写首页的行为,提高纵隔肿瘤ICD疾病编码的准确性。方法调取某三甲肿瘤专科医院2021年1—7月出院病案,按照ICD-9手术编码相关原则进行检索,并对其病历首页出院诊断及病理诊断依据疾病和有关健康问题的国际统计分类ICD-10进行质控和分析。用Excel表格进行错误类型的统计工作。结果质控病案首页88份,存在的错误类型包括形态学编码漏填或错误和疾病诊断编码错误。其中,形态学编码漏填或错误35份,占39.77%,其中以形态学编码错误为主;疾病诊断编码错误47份,占53.41%,其中纵隔肿瘤的部位编码混淆居多。结论临床医师在首页诊断填写存在概念混淆,编码员存在临床知识缺乏,对国际疾病分类ICD-10编码知识理解不够深入,临床医师与编码员缺乏沟通。通过深入推进临床医师ICD-10疾病编码培训,设立科室专职编码质检人员,邀请临床医师讲授专业知识,促进全院病案首页填写质量的提高。

Objective To analyze the cases of wrong coding of mediastinal tumors in a grade III cancer hospital,improve clinicians’awareness of the quality of filling in the first page,standardize doctors’behavior of filling in the first page,and improve the accuracy of ICD disease coding of mediastinal tumors.Methods The discharge medical records of a top three cancer hospital from January to July 2021 were retrieved according to the relevant principles of ICD-9 operation coding,and the discharge diagnosis and pathological diagnosis on the first page of the medical record were controlled and analyzed according to the international statistical classification of diseases and related health problems ICD-10.Use Excel table to make statistics of error types.Results There were 88 quality control medical records on the first page.The types of errors included missed filling or wrong coding in morphology and wrong coding in disease diagnosis.Among them,35(39.77%)were incorrect in morphological coding,47(53.41%)were incorrect in diagnosis,and most of them were confused in the coding of mediastinal tumor.Conclusion Clinicians have conceptual confusion in filling in the diagnosis on the home page,coders lack clinical knowledge,lack of in-depth understanding of ICD-10 coding knowledge,and lack of communication between clinicians and coders.By further promoting the ICD-10 disease coding training for clinicians,setting up full-time coding and quality inspection personnel in departments,and inviting clinicians to teach professional knowledge,we can improve the quality of filling in the first page of medical records in the whole hospital.