产科常见易错手术操作编码案例分析

Case Analysis of Common Error-prone Operation Coding in Obstetrics

在ICD-9-CM-3中产科系统的手术操作因临床书写相同,手术操作过程相似,但编码往往不同,编码员在编码时常有误编。列举某院病案质控发现的产科手术操作编码错误较多的几种编码,例如催产素静滴、人工破膜引产术、会阴切开术、会阴裂伤修补术、剖宫产术、子宫球囊置入术等,探讨分析其编码要点及查找方法,总结产科中催产素静滴编码时需要注意是否药物增强分娩;人工破膜引产术根据操作时是否进入产程编码于73.01、73.09;会阴切开术根据是否伴有产钳或真空吸引操作编码于73.6、72.1、72.21、72.31、72.71;会阴裂伤修补术根据疾病性质编码于71.71、75.69、71.79;剖宫产术根据目的不同编码于74.1、74.91;子宫球囊置入术根据置入球囊目的不同编码于69.91、73.1、75.8;分娩后清宫术根据术式编码于69.02、69.52。编码员需提升临床基础知识和病案专业技能,熟练掌握产科手术操作编码规则,并与临床保持良好沟通,才能提高编码准确性。

In ICD-9-CM-3,the surgical operations in the obstetric system are clinically written the same and the surgical procedures are similar,but the coding is often different.Thus,coders often make mistakes when coding.By listing several coding errors found in the quality control of medical records in a hospital for obstetric surgery operations,such as oxytocin intravenous infusion,artificial rupture of membranes to induce labor,episiotomy,perineal laceration repair,cesarean section,uterine balloon implantation,etc,this study discusses and analyzes the coding points and search methods,and summarizes the need to pay attention to whether the drug enhances labor when coding oxytocin intravenous infusion in obstetrics.Artificial rupture of membranes was coded in 73.01 and 73.09 according to whether the operation entered the labor process;Episiotomy was coded in 73.6,72.1,72.21,72.31,and 72.71 according to whether it was accompanied by forceps or vacuum suction;The codes of perineal laceration repair were 71.71,75.69,and 71.79 according to the nature of the disease;The codes of cesarean section were 74.1 and 74.91 according to the different purposes;The codes of uterine balloon implantation were 69.91,73.1,and 75.8 according to different purposes;Curettage after delivery was coded in 69.02,69.52 according to the surgical procedure.In order to improve the accuracy of coding,coders need to improve their basic clinical knowledge and professional skills in medical records,master the coding rules of obstetric operations skillfully,and maintain good communication with the clinic.