5例梭形细胞肿瘤ICD-10编码分析

Analysis of ICD-10 Coding in 5 Cases of Spindle Cell Tumor

针对梭形细胞肿瘤病理分型多样,造成编码困难,分析案例查找出其相应ICD-10编码,总结编码思路并提出提高编码质量的建议与措施。5例梭形细胞肿瘤的编码分别是声门下恶性肿瘤C32.2,鳞状细胞癌M8070/3;下肢结缔组织和其他软组织良性肿瘤D21.2,包括髋,血管平滑肌瘤M8894/0;周围神经和自主神经系统良性肿瘤D36.1,神经鞘瘤M9560/0;胃体恶性肿瘤C16.2,胃肠间质瘤M8936/3;食管良性肿瘤D13.0,平滑肌瘤M8894/0。梭形细胞肿瘤的编码并非一成不变,编码员需加强对梭形细胞肿瘤的认识,认真查阅病案资料,明确肿瘤形态与动态,严格遵循肿瘤编码查找步骤进行编码查找与核对。

In response to the diverse pathological subtypes of spindle cell tumors causing coding difficulties,case studies were conducted to identify their corresponding ICD-10 codes,summarize coding ideas,and propose suggestions and measures to improve coding quality.The codes of 5 cases of spindle cell tumors are:C32.2 malignant neoplasm of subglottis,M8070/3 squamous cell carcinoma NOS;D21.2 benign neoplasms of connective and other soft tissue of upper limb,including hip,M8894/0 angiomyoma;D36.1 benign neoplasms of peripheral nerves and autonomic nervous system;M9560/0 neurilemmoma NOS;C16.2 malignant neoplasm of stomach body,M8936/3 gastrointestinal stromal tumors;D13.0 Benign neoplasms of the esophagus,M8890/0 leiomyoma NOS.The coding of spindle cell tumors is not fixed.Coders need to strengthen their understanding of spindle cell tumors,carefully review medical records,clarify tumor morphology and dynamics,and strictly follow the tumor coding search steps for coding search and verification.Strengthening the standardized writing training for physician diagnosis,enhancing the clinical knowledge reserve of coders,and increasing communication between physicians and coders are effective ways to improve coding accuracy.