脊柱侧弯相关疾病和手术ICD编码的探讨

Exploration of Spinal Scoliosis Related Diseases and Surgical ICD Coding

脊柱侧弯在临床工作中常基于部位、严重程度及代偿弯曲等进行分型,而脊柱侧弯ICD-10的分类轴心是病因,包括M41.0-M41.2特发性脊柱侧弯、M41.3胸源性脊柱侧弯、M41.4神经肌肉性脊柱侧弯、Q76.3骨先天性畸形引起的脊柱侧弯、Q67.5脊柱先天性变形、M41.5其他继发性脊柱侧弯、A18.0M49.0*结核性脊柱侧弯等。编码员应仔细阅读病历,结合患者年龄、既往史、手术史等资料,与临床医师沟通,确认脊柱侧弯的具体病因。脊柱侧弯常见的手术有77.29椎体截骨术、80.99半椎体切除术、81.0脊柱融合、78.59生长棒置入术等,编码员应注意相关ICD-9-CM-3编码类目说明,结合手术记录正确理解另编码和省略编码的含义,才能完善脊柱侧弯疾病和手术的ICD分类。

Scoliosis is often classified in clinical work based on location,severity and compensatory curvature,and the ICD-10 classification axis of scoliosis is the cause.These include M41.0-M41.2 idiopathic scoliosis,M41.3 thoracic scoliosis,M41.4 neuromuscular scoliosis,Q76.3 scoliosis caused by congenital bone malformation,Q67.5 congenital deformity of the spine,M41.5 other secondary scoliosis,and A18.0†M49.0*tuberculous scoliosis.Coders should carefully read medical records and communicate with clinicians to confirm the specific cause of scoliosis in combination with the patient's age,past history,and surgical history.Common operations for scoliosis include 77.29 vertebral osteotomy,80.99 hemivertebraectomy,81.0 spinal fusion,and 78.59 growth rod insertion,etc.Coders should pay attention to the description of relevant ICD-9-CM-3 coding categories,and correctly understand the meaning of alternative coding and omitted coding combined with surgical records.To improve the ICD classification of scoliosis disease and surgery.