脑室出血相关手术编码探讨

Exploration of Surgical Coding Related to Ventricular Hemorrhage

脑室出血是危重的急性脑血管病,多继发于自发性脑出血,且常引发脑积水,手术是治疗脑室出血及相关并发症的主要方式。目前国内对脑室出血相关手术治疗基本框架虽已确定,但随着医学技术的快速发展,医疗理念的推陈出新,衍生出多种术式,编码时对各种术式的鉴别存在难度。通过依据《全国医疗技术项目服务技术规范(2023年版)》、国际疾病分类第九版临床修订本手术与操作(ICD-9-CM-3,2011版)的编码规则,总结术式核心理念与编码查找路径比较术式之间的异同并举例。相关编码有脑室血肿穿刺术01.09、脑室血肿清除01.39、脑室外引流术02.21、颅内脑室分流02.22、颅外脑室分流02.31-02.39。编码员在实际工作中应深入理解相关术式的临床分类,通过编码分类轴心提取关键信息,结合实际与编码规则进行另编码或省略编码,提高编码的准确性与完整性。

Ventricular hemorrhage is a critical acute cerebrovascular disease,mostly secondary to spontaneous cerebral hemorrhage,and often triggers hydrocephalus,and surgery is the main way to treat ventricular hemorrhage and related complications.Although the basic framework of surgical treatment related to ventricular hemorrhage has been determined in China,with the rapid development of medical technology and the introduction of new medical concepts,a variety of surgical styles have been derived,which involve more operational codes.It is difficult to identify the various surgical styles at the time of coding.By referring to the National Technical Code for Medical Technology Program Services(2023 Edition),and based on the coding rules of the International Classification of Diseases,Ninth Edition,Clinical Modification,Surgery and Operations(ICD-9-CM-3,2011 Edition),combined with the principles of surgery,we summarize the core concepts of the procedures and the coding pathways to find the differences and similarities between the procedures and give examples,and summarize the relevant codes as follows:Ventricle hematoma puncture 01.09,Ventricular hematoma removal 01.39,External ventricular drainage 02.21,Intracranial ventricular shunt 02.22,Extracranial ventricular shunt 02.31-02.39.Coders should have an in-depth understanding of the clinical classification of the relevant procedures,surgical procedures and extract key information through the coding axes,and at the same time pay attention to combining the practical and coding rules to code or omit the code,to improve the accuracy and completeness of the code.Improve the accuracy and completeness of coding.