脊柱融合术ICD-9-CM-3编码解析

ICD-9-CM-3 Coding Analysis of Spinal Fusion

脊柱融合术是脊柱外科最常见的术式,其术式多样,ICD-9-CM-3编码不同。通过分析ICD-9-CM-3分类中81.0不同细目的含义,结合临床实际,应用手术案例,解析脊柱融合术的编码思路。根据手术的入路与融合的具体部位确定主要手术编码为81.0下的具体细目,颅颈、颈椎、颈胸椎融合分类于81.01-81.03,胸椎、胸腰椎的融合术分类于81.04-81.05,腰椎、腰骶椎的融合术分类于81.06-81.08,不使用未特指的脊柱融合术81.00,同时须另编码融合椎骨的总数81.62-81.64。再根据手术记录的具体内容,选择附加编码。并在充分理解编码规则的基础上,注意应省略的编码:骨移植术78.0、椎骨内固定术(与融合同一水平)78.59与利用术中切除的自体碎骨进行植骨的采集骨切除术。编码员只有积极参加编码培训,对编码原则进行系统学习,不断提升对医学知识的认知水平,才能正确编码。

Spinal fusion is the most common surgical procedure in spinal surgery,and because of the diversity of the surgical techniques,the ICD-9-CM-3 coding is different.This article analyzes the meanings of the different subheadings under 81.0 in the ICD-9-CM-3 classification system,and combines clinical actual application surgical cases to elucidate the coding strategy for spinal fusion.The main surgical code is determined based on the entry route and the specific fusion site of the surgery.Cranio-cervical,cervical,and thoraco-cervical spinal fusion is classified under 81.01 to 81.03,thoracic and thoraco-lumbar spinal fusion is classified under 81.04 to 81.05,lumbar and lumbosacral spinal fusion is classified under 81.06 to 81.08,and try to avoid 81.00(spinal fusion,not otherwise specified),and the total number of fused vertebrae must be coded separately with codes 81.62 to 81.64.Based on the specific content of the surgical record,additional codes are selected.Attention should be paid to the codes that should be omitted in a full understanding of the coding rules,such as bone grafting surgery 78.0,vertebral internal fixation surgery(at the same level as the fusion)78.59,and the collection of bone grafting by removing autologous fragmented bone during the surgery.Only by actively participating in coding training,systematically learning coding principles,and continuously improving their understanding of medical knowledge,can coders correctly code.