恶性黑色素瘤ICD编码问题分析

Analysis on the Problems and Causes of ICD Coding in Malignant Melanoma

目的分析恶性黑色素瘤编码错误原因,探讨正确查找恶性黑色素瘤编码的思路与方法。方法采用随机抽样的方法抽取某肿瘤专科医院2015年-2017年黑色素瘤病区的300份病例资料,与临床医师沟通,分析其病因、病理,并按照ICD-10分类原则探寻正确编码。结果恶性黑色素瘤肿瘤部位编码错误最多,占错误病例总数的62.5%;其次是恶性黑色素瘤肿瘤形态学编码错误与其他类型错误,分别占错误病例总数的25%和12.5%。编码错误的原因分别为编码员不熟悉规则(43.75%)、不区分具体的恶性黑色素瘤形态学编码(25%)、部位编码混淆(18.75%)和医师填报错误,编码员根据临床医师填报的错误诊断进行编码,造成编码错误占12.50%。结论提高恶性黑色素瘤病例编码的质量,需要编码员熟练掌握ICD编码规则,不断学习积累相关医学知识,与临床医师多沟通,加强医师首页填报的规范培训,此外,设立专门的学科编码员也是提高编码正确率的有效途径。

Objectives To analyze the cause of the coding error of malignant melanoma, and explore the ideas and methods for finding the coding of malignant melanoma. Methods Using random sampling method to extract a tumor specialized subject hospital melanoma from 2015 to 2017 units of 300 medical records, communicating with clinicians, analyzing the etiology, pathology, and searching for the right in accordance with the principle of classification of ICD-10 code. Results Malignant melanoma tumors have the most coding errors, accounting for 62.5% of the total number of medical records;followed by malignant melanoma tumor morphology coding errors and other types of errors, accounting for 18.8% and 12.5% of the total number of false medical records, respectively.The reasons for the coding errors are: the coder is not familiar with the rules(43.75%), the coder does not distinguish the specific malignant melanoma morphological coding(25%), the coding part code confusion(18.75%), the physician fills in the error, the coder With the error(12.50%). Conclusion To improve the quality of malignant melanoma medical records, the coder needed to master the ICD coding rules, and continuously learn to accumulate relevant medical knowledge;communicate with clinicians and strengthen the standardized training for the doctor’s front page. In addition, the establishment of specialized subject coders was also an effective way to improve the accuracy of coding.