70例原发性IgA肾病编码质量分析

Analysis on the Coding Quality of 70 Cases of Primary IgA nephropathy

目的分析某院近两年原发性IgA肾病ICD-10编码错误的原因,提高编码正确率。方法选取某院肾病科2022年1月1日-2023年12月31日出院诊断为原发性IgA肾病的病案共70份,按照ICD-10分类原则进行逐份核查,对住院病案首页疾病编码存在的问题进行汇总分析。结果70例原发性IgA肾病中有38例编码错误,错误占比54.3%,其中未依据主导词指示选择类目的7例,未查阅病理报告致编码错误的23例,缺乏肾病病理学知识致编码错误的11例,未明确病理分型误用.8亚目的4例。结论提高IgA肾病编码正确率,需建立正确的病理分型与编码对照关系,加强临床医师诊断书写规范性以及提升编码员业务水平。

Objectives To analyze the causes of ICD-10 coding errors for primary IgA nephropathy in a hospital in the past two years,and improve the coding accuracy.Methods A total of 70 medical records diagnosed as primary IgA nephropathy in the nephrology department of a certain hospital from January 1st,2022 to December 31st,2023were selected and checked one by one according to the ICD-10 classification principle.The presence of disease codes on the home page of the inpatient medical records was A summary analysis of the issues.Results Among the 70 cases of primary IgA nephropathy,38 cases had coding errors,with errors accounting for 54.3%,Among them,there were 7 cases where the category was not selected based on the dominant word indication,23 cases of coding errors due to failure to review pathological reports,11 cases where coding errors were caused by a lack of knowledge of renal pathology,and 4 cases with unclear pathological classification but incorrect use of.8 suborders.Conclusions To improve the accuracy of IgA nephropathy coding,it was necessary to establish a correct correspondence between pathological classification and coding,strengthen the standardization of clinical doctor diagnosis writing,and improve the professional level of coders.