ICD-9-CM-3手术操作中部分省略编码分析

Analysis of some omit codes in the operation of ICD-9-CM-3

目的分析某三甲医院手术操作中部分“省略编码”的编码准确性,提出改进措施。方法通过病案统计管理系统,检索某三甲医院2022年6月1至2022年12月31日出院病案信息中涉及“省略编码”的病案1669份,包括椎管减压术618份、肠吻合术362份、房间隔穿刺术224份、心脏电生理检查207份、动脉穿刺术157份、心电监测101份,应用回顾性分析方法对编码逐一审核,将统计结果分析汇总。结果1669份病案中有649份存在“省略编码”错误编码问题,总错误编码率38.9%。其中错误率最高的是动脉穿刺术,错误率67.5%,其次是房间隔穿刺术,错误率42.9%,椎管减压术错误率42.7%,心脏电生理检查错误率38.2%,心电监测错误率28.7%,错误率最低的是肠吻合术20.7%。结论涉及上述六种“省略编码”的手术操作中,动脉穿刺术、房间隔穿刺术、椎管减压术最易出错。编码员需认真阅读手术记录,仔细核查工具书,熟练掌握编码规则,积累丰富的临床与专业知识,从而保证手术操作编码的准确性。

Objectives To analyze the code accuracy of part of"omit code"in the operation of a tertiary hospital,and propose improvement measures.Methods In this paper,a total of 1669 medical records involving"omit code"in a Three A and Tertiary Hospital from June 1st,2022 to December 31st,2022 were retrieved through the medical record statistics management system,including 618 cases of spinal canal decompression,362 cases of enterostomy,224 cases of atrial septal puncture,207 cases of intraoperative electrophysiological examination,157 cases of arterial puncture,101 cases of intraoperative electrical monitoring and continuous blood oxygen saturation monitoring,apply retrospective analysis method to audit one by one and analyze and summarize the statistical results.Results 649 out of 1669 cases had the problem of"omit code"and the error code rate was 38.9%.Among them,the highest error rate is arterial puncture,with an error rate of 67.5%,the second highest error rate is atrial septal puncture,with an error rate of 42.9%,vertebral canal decompression,with an error rate of 42.7%,intraoperative electrophysiological examination,with an error rate of 38.2%,intraoperative electrical monitoring,and continuous oxygen saturation monitoring,with an error rate of 28.7%,the lowest error rate is enterostomy,with an error rate of 20.7%.Conclusions Among the six"omitted coding"surgical procedures mentioned above,arterial puncture,atrial septal puncture,and spinal canal decompression were the most prone to errors.Coders need to carefully read the surgical records,carefully check the catalog of reference books,master coding rules,and accumulate rich clinical expertise to ensure the accuracy of surgical operation coding.