肌腱修补手术ICD-9-CM-3编码浅析

Analysis of ICD-9-CM-3 Coding in Tendon Repair Surgery

肌腱修补术在临床上是一个广义的概念,对应的术式多样。由于编码员对术式的不了解及临床医师书写术式的不规范,导致肌腱修补手术的编码错误。通过对不同肌腱修补手术的列举,说明不同术式的区别,确定主导词从而查询正确的编码。单纯的手部肌腱缝合修补术82.42-82.45(其他部位83.64),手部肌腱固定于骨的修补术82.85(其他部位83.88),手部肌腱移植修补术(插补)82.79(其他部位83.81),手部肌腱转位替代受损肌腱功能修补术82.56(其他部位83.75)。同时对6例临床实际手术记录进行解析,分析编码人员在编码过程中易混淆的知识点,通过提高编码员对临床知识的掌握程度及手术过程的熟悉程度,加强对ICD-9-CM-3中英文注释的解读,提升此类手术编码的准确性。

Tendon repair is a broad concept in clinical practice,and the corresponding operation methods are various.Because coders do not understand the operation and clinicians write the operation is not standard,resulting in tendon repair surgery coding errors.By enumerating different tendon repair operations,the difference between different operations is explained,and the dominant words are determined to query the correct coding.Simple suture repair of hand tendon 82.42-82.45(83.64 in other parts),repair of hand tendon fixed to bone 82.85(83.88 in other parts),and repair of hand tendon transplantation(interpolation)82.79(83.81 in other parts).Tendon transposition of hand to replace functional repair of damaged tendon 82.56(83.75 elsewhere).At the same time,the actual clinical surgical records of 6 cases were analyzed,and the knowledge points easily confused by coders in the coding process were analyzed.By improving the coders'grasp of clinical knowledge and familiarity with the surgical process,the interpretation of ICD-9-CM-3 notes in both Chinese and English was strengthened to improve the accuracy of such surgical coding.