慢性鼻窦炎的编码分析

Coding Analysis of Chronic Sinusitis

目的通过回顾分析某三甲医院近3年慢性鼻窦炎相关编码数据,探讨错误编码的主要原因,提高编码员对慢性鼻窦炎编码的准确性。方法利用病案查询系统检索出某院2014年12月-2017年9月住院的714份慢性鼻窦炎并手术治疗的病案,查找包括粗编、漏编、错编等编码质量缺陷,对缺陷原因进行回顾性分析。结果 714份病案中发现共312例编码存在缺陷,错误编码率为43. 6%;其中手术编码与术式不对应18例,占5. 8%;病损位置诊断编码遗漏101例,占32. 4%等。结论慢性鼻窦炎分类复杂,临床医师应书写该疾病相关分型,而编码人员则应加强细化编码规则,协同临床医师将病案编码更加专业化,更好的为临床服务。

Objective To explore the main reasons for the wrong medical coding and so as to improve the medical coding accuracy of chronic sinusitis,the coding data of chronic sinusitis in a third-class hospital in recent three years were reviewed and analyzed.Methods 714 cases of chronic sinusitis who had been hospitalized and had operations in our hospital from December 2014 to September 2017 were searched by medical record inquiry system to find out the coding defects including rough coding,missing coding and wrong coding and analyze the causes of these defects retrospectively.Results Among them,there are 18 cases in which surgical procedure and coding did not correspond,accounting for 5.8%.101 cases was missed lesion position diagnosis code,accounting for 32.4%.Conclusion The classification of chronic sinusitis is complicated.Clinicians should fill the classification of the disease;The coding staff should strengthen the refinement coding rules,and cooperate with clinicians to make the medical code more professional to serve the clinic better.