胆石症相关手术操作编码探讨

Surgical procedure coding for cholelithiasis

目的探讨胆石症相关手术操作编码,分析常见编码错误原因,提出改进方案。方法介绍胆石症相关医学知识,罗列胆石症的常见手术操作及ICD-9-CM-3编码,总结手术操作编码的查找路径,并结合临床实例,对编码错误问题进行总结分析。结果剖腹去除胆囊结石编码于51.04,剖腹去除胆总管结石编码于51.41,剖腹去除其它胆管结石编码于51.49。腹腔镜及消化内镜下去除胆道结石均编码于51.88,经皮胆囊取石编码于51.88,经皮胆总管取石编码于51.96,经皮其它胆管取石编码于51.98。临床医生的不规范书写及编码员自身业务能力的不足,容易导致编码错误。结论加强临床沟通,规范病历书写,编码员与临床医生相互学习,同步提升自身业务水平,病案科内建立编码的多重质控体系,可降低手术操作编码的错误率。

Objective To explore the surgical procedure coding for cholelithiasis,analyze common coding errors,and propose improvement solutions.Methods The knowledge on cholelithiasis was illustrated.Common surgical procedures for cholelithiasis and their ICD-9-CM-3 codes were introduced.The search path for surgical procedure codes was summarized.Errors in coding were analyzed by combining clinical cases.Results Open cholecystectomy for gallbladder stones was coded as 51.04,for common bile duct stones as 51.41,and other bile duct stones as 51.49.Laparoscopic and endoscopic removal of biliary stones were coded as 51.88,percutaneous gallbladder stone extraction as 51.88,common bile duct as 51.96,and other bile duct as 51.98.Non-standard writing by clinical physicians and insufficient coding skills of coders was easy to lead to coding errors.Conclusion Errors in surgical procedure coding for cholelithiasis can be reduced by strengthening clinical communication,standardizing medical record writing,promoting mutual learning between coders and clinical physicians,enhancing their own professional skills,and establishing a multi-level quality control system for coding in the Medical Record Department.