原始神经外胚瘤编码分析

Coding Analysis of Primitive Neuroectodermal Tumor

目的通过分析某三甲医院原始神经外胚瘤错误编码,提高原始神经外胚瘤编码准确性。方法以'M9473/3'和'M9364/3'为条件检索某三甲医院2008年-2017年的出院病案,按照ICD-10编码原则及相关临床病理知识对检索出的病案进行逐个核查。用excel软件统计错误编码及其相关临床病理内容。结果以'M9473/3'为条件,检索出39例,以'M9364/3'为条件,检索出0例。39例肿瘤编码为M9473/3的患者中,有8例病理报告中免疫组化结果 CD99呈阳性并且存在神经分化物,提示外周型原始神经外胚瘤,编码错误。结论编码人员必须深入理解国际疾病分类中假定分类原则,认真阅读病案、病理报告,查阅相关资料,加强医学知识的学习,积极与临床医师、病理医师以及其他相关科室沟通,保证编码准确率。

Objective To improve the coding accuracy of primitive neuroectodermal tumors by analyzing the false coding of primitive neuroectodermal tumors in a top three hospital.Methods Retrieving the medical records of a top three hospital from 2008 to 2017 on the condition of'M9473/3'and'M9364/3',according to the ICD-10 coding principle and related clinical pathology knowledge,the retrieved medical records are checked one by one.The error coding and its related clinical pathology were statistically analyzed with excel software.Results Based on the condition of'M9473/3',39 cases were retrieved.Based on the condition of'M9364/3',0 cases were retrieved.39 patients with tumors encoded as M9473/3.In 8 pathological reports,immunohistochemistry results were positive for CD99 and neuropeptides,suggesting peripheral primitive neuroectodermal tumors,coding error.Conclusions Coders must have an in-depth understanding of the principles of hypothetical classification in the International Classification of Diseases.Carefully reading medical records,pathological reports,consulting relevant materials,strengthening the study of medical knowledge,and actively communicating with clinicians,pathologists and other related departments to ensure the accuracy of coding.