摘要
斜视是眼科常见疾病,影响双眼的正常功能和外观,斜视手术的术式和组合方式多样,术式内容和难度也存在区别,但在ICD-9-CM-3中对眼外肌手术的分类较为简略,是日常编码工作中的易错点和难点。ICD编码中眼外肌从眼球暂时脱离手术分类于15.1和15.3;眼外肌其他手术分类于15.2和15.4;移位术分类于15.5;前2类手术需区分眼外肌条数,同类手术中双眼眼外肌条数一并计算。本文按斜视手术的ICD分类介绍临床常见术式和编码查找方式,以实际案例进行错误编码分析,总结编码经验和改进建议。医院根据自身的临床和科研需求对编码进行扩展、提高编码员本专业和临床专科知识水平、临床医师加强病历书写规范化培训有利于提高编码的质量。
Strabismus is a common ophthalmic disease that affects the normal function and appearance of eyes. There are various surgical methods and combinations of strabismus surgery, and the content and difficulty of surgical methods are also different. However, the classification of extraocular muscle surgery in ICD-9-CM-3 relatively simple, which is the error prone and difficult point in daily coding. According to ICD code, the operations of extraocular muscle involving temporary detachment from globe are classified as 15.1 and 15.3;other operations on extraocular muscle are classified as 15.2 and 15.4;and transposition is classified as 15.5. The number of extraocular muscles in the first two types of surgery should be distinguished, and the number of extraocular muscles in both eyes in the same type of operation is counted together. According to the ICD classification of strabismus surgery, this paper introduces the common clinical surgical methods and coding search methods, analyzes incorrect codes with actual cases, and summarizes the coding experience and improvement suggestions. The hospital should expand the coding according to its own clinical and scientific research needs, improve the professional and clinical knowledge level of coders, and strengthen the standardized training of medical record writing for clinicians, which is conducive to improve the quality of coding.
作者
杨洋
曾芳
刘慧悦
廖超
张静
Yang Yang;Zeng fang;Liu Huiyue;Liao Chao;Zhang Jing(Department of Medical Record Management and Statistical Information,Xiangya hospital,Central South University,Changsha 410008,Hunan Province,China;不详)
出处
《中国病案》
2021年第1期59-62,共4页
Chinese Medical Record
基金
中南大学湘雅医院管理研究基金项目(2019GL15)。
