经内镜逆行胰胆管造影术相关操作编码分析

Coding Analysis of Relevant Operations in Endoscopic Retrograde Cholangiopancreatography

目的 调查经内镜逆行胰胆管造影术(ERCP)及其治疗操作的编码情况,分析问题并提出改进措施,以提高编码质量。方法 调取某院2021年1月1日至2022年12月31日出院的409份行经内镜逆行胰胆管造影术病案进行回顾性核查,对手术操作编码缺陷进行统计,分类汇总编码缺陷原因。结果 409份病案中有问题病案69份,错误率达16.87%,69份问题病案中累计错误条目数93条,有11份同时存在主要手术操作编码与其他手术编码错误,主要手术操作编码错误32条,占总错误条目数的34.41%;其他手术操作编码错误61条,占总错误条目数的65.59%。结论 编码员未严格遵守编码规则、临床知识储备不足,与临床沟通不足、临床书写不规范是经内镜逆行胰胆管造影术及其治疗操作编码错误的主要原因。编码员需增加临床知识储备,主动与临床医师沟通,提高ERCP及其治疗操作的编码质量。

Objectives To investigate the coding situation of endoscopic retrograde cholangiopancreatography(ERCP)and its therapeutic operation,analyze the problems and propose improvement measures to improve the coding quality.Methods A total of 409 inpatient cases of endoscopic retrograde cholangiopancreatography(ERCP)and its treatment procedures discharged from a hospital from January 1st,2021 to December 31st,2022 were reviewed retrospectively,and the coding defects of the operation procedures were counted,and the causes of coding defects were classified and summarized.Results Among the 409 medical records,there were 69 problematic medical records,and the error rate was 16.87%.There were 93 wrong entries in the 69 problematic medical records,11 of which had errors in the coding of major surgical procedures and other surgical procedures,and 32 of them had errors in the coding of major surgical procedures,accounting for 34.41%of the total number of wrong entries.There were 61 coding errors in other surgical procedures,accounting for 65.59%of the total number of wrong entries.Conclusions Through the cause analysis,the coder's failure to strictly abide by the coding rules,insufficient clinical knowledge,insufficient communication with the clinic,and irregular clinical writing were the main reasons for coding errors in endoscopic retrograde cholangiopancreatography and its treatment operations.Coders needed to strengthen their own learning,increase clinical knowledge reserves,use ICD-9-CM-3 reference books to find and check codes,actively communicate with clinical practices,and improve the coding quality of ERCP and its treatment operations.