胰腺假性囊肿常见术式及编码探讨

Analysis of Common Surgical Procedures and ICD-9-CM-3 Coding Cases of Pancreatic Pseudocysts

胰腺假性囊肿外科手术治疗术式较多,由于临床医师的住院病案首页填写不规范,编码员易混淆手术名称,导致编码错误。胰腺假性囊肿外科手术治疗,临床上常用的手术方式包括外引流术:导管外引流术52.01,内镜下鼻胰管外引流术52.97;内引流术:经吻合内引流术52.4,胰管支架内引流术52.93;切除术:囊肿壁部分切除术(袋形缝合术)52.3,囊肿伴部分胰尾切除术52.52,囊肿完整切除术52.22。结合病例梳理以上7种胰腺假性囊肿手术治疗术式及编码,并根据国家临床版手术及操作编码3.0字典库进行编码分析,有助于编码员熟悉各种胰腺假性囊肿的术式,丰富编码专业知识及临床知识,以提高胰腺假性囊肿的手术编码准确率。

There are many surgical treatments for pancreatic pseudocyst.However,due to the non-standard filling of the front page of clinical doctors'medical records,coders can easily confuse the names of surgeries,leading to coding errors.Surgical treatment of pancreatic pseudocysts commonly used clinical surgical methods include external drainage:catheter external drainage coded as 52.01 and endoscopic nasopancreatic cyst external drainage coded as 52.97;Internal drainage:anastomotic internal drainage coded as 52.4 and pancreatic stent internal drainage coded as 52.93;Excision surgery:partial excision of cyst wall(bag shaped suture)coded as 52.3,partial pancreatectomy of cyst with tail coded as 52.52,and complete cyst resection coded as 52.22.This study introduces the above 7 surgical treatment methods and coding for pancreatic pseudocysts based on case studies and performs corresponding coding analysis based on the National Clinical Edition 3.0 Dictionary of Surgical and Operational Codes.This will help coders become familiar with various surgical procedures for pancreatic pseudocysts,enrich coding expertise and clinical knowledge,and improve the accuracy of surgical coding for pancreatic pseudocysts.