胸壁肿瘤手术编码分析

Coding Analysis of Chest Wall Tumor Surgery

手术编码构成包括部位、术式、入路和疾病性质。胸壁肿瘤切除术和胸壁重建术是胸外科常见的手术方式,根据手术部位及疾病性质不同,胸壁肿瘤切除术分为胸壁骨组织切除术(77.61、77.81、77.91)、胸壁软组织或伴肋骨切除术(34.4),胸壁皮肤和皮下组织切除术(86.3、86.4);根据手术部位及手术术式不同,胸壁重建术分为胸膜重建术(34.93)、胸壁骨骼重建术(78.01、78.41、84.94)、胸壁软组织重建术(34.79、86.6、86.7)。临床医师要准确填写病案首页手术名称并详细记录手术过程,编码员对临床医师书写的手术名称进行编码时,应认真阅读手术记录,根据解剖部位、疾病性质、手术过程准确编码,查找的编码应核对类目表,仔细阅读包括与不包括内容,从而降低编码错误率,提高病案首页编码质量。本文拟通过手术案例,探讨以上手术对应的ICD-9-CM-3编码。

Surgical coding includes location,operation,approach and nature of the disease.Chest wall tumor resection and chest wall reconstruction are common surgical methods in thoracic surgery.According to the different surgical sites and the nature of the disease,chest wall tumor resection is divided into chest wall bone resection(77.61,77.81,77.91),chest wall soft tissue or rib resection(34.4),chest wall skin and subcutaneous tissue resection(86.3,86.4).According to different surgical sites and surgical procedures,chest wall reconstruction is divided into pleural reconstruction(34.93),chest wall bone reconstruction(78.01,78.41,84.94),chest wall soft tissue reconstruction(34.79,86.6,86.7).Clinicians should accurately fill in the name of the operation on the front page of the medical record and record the operation process in detail.When the coder encodes the operation name written by the clinician,the operation record should be carefully read.According to the anatomical site,the nature of the disease and the operation process,the code should be accurately coded.The search code should check the category table and carefully read the inclusion and exclusion content,so as to reduce the coding error rate and improve the coding quality of the front page of the medical record.This article intends to explore the ICD-9-CM-3 coding corresponding to the above surgery through surgical cases.