摘要
目的对某三甲医院住院病案首页同种疾病编码但不同手术操作编码(ICD-9-CM-3)的DRGs分组情况进行分析,探讨编码员易混淆的三类手术操作编码的分组影响。方法依据2018年1月1日-2018年12月31日的18691份医保患者出院病例的DRGs分组反馈结果,选取编码员易混淆的肠套叠复位术、室间隔缺损修补术、机械性辅助通气三类手术操作编码的案例,通过Excel电子表格的筛选功能进行对比分析,研究同种疾病编码但不同的手术操作编码与分组名称之间的对应关系,分类统计不同的手术操作编码DRGs分组例数。结果通过某市CIS-DRGs(柳州版)点数法分组方案分组后,97例肠套叠的病例、19例室间隔缺损的病例、46例新生儿呼吸窘迫综合征的病例,由于不同的手术操作编码每类病例分别形成2个不同的DRGs分组。结论住院病案首页同种疾病编码但不同种手术操作编码(ICD-9-CM-3)可引发不同的DRGs分组,因此编码员对易混淆的手术操作编码进行分类时,应更加谨慎,避免因错编码导致病例分组错误。
Objective To analyze the DRGs grouping result with same disease mode but different operation mode of front page of medical records in a grade 3 and first-class hospital of LiuZhou.Explore the grouping effect of three types of confused operation mode by coder.Methods Based on the 18691 cases of DRGs grouping feedback result from January 2018 to December 2018,choose three types of confused operation mode(Intussusception,Ventricular septal defect,Neonatal respiratory distress syndrome) that coder are prone to error coding.Research the corresponding relationship between the operation mode and the grouping name by applying the screen function of Excel.Classify and statistics the numbers of DRGs group with different operation mode.Results After grouping by CIS-DRGs(LiuZhou),97 cases Intussusception,19 cases Ventricular septal defect,46 cases Neonatal respiratory distress syndrome are divided into two different groups because of different operation mode.Conclusion The same disease mode but different operation mode can lead to different DRGs grouping.As a result,coder must be very cautious to the classification of the confused operation mode and avoid incorrect coding so that cause error grouping.
作者
覃陈
Qin Chen(Medical Record Department,Liuzhou Maternal and Child Healthcare Hospital,Liuzhou 545001,Guangxi Zhuang Autonomous Region,China)
出处
《中国病案》
2019年第10期35-37,共3页
Chinese Medical Record
