摘要
腰椎融合术广泛应用于临床治疗腰椎滑脱、腰椎间盘突出等疾病,腰椎融合术需要多个手术编码来描述手术过程,需注意区分主要编码、不遗漏另编码、确定省略编码,其主要编码分类轴心为手术入路,另编码根据手术情况略有不同,本文通过1份腰椎融合术实例了解手术过程,确定融合术手术入路、切除部位、术中使用的材质、Cage融合部位、骨移植情况、融合椎骨数量及其他情况,才能给予完整准确分类编码,这就需要编码员不但要认真阅读手术记录,熟练掌握编码规则,还要熟知解剖学知识,才能做好手术分类编码工作。
Lumbar fusion is widely used in the clinical treatment of lumbar spondylolisthesis,lumbar disc herniation and other diseases.Lumbar fusion requires multiple surgical codes to describe the operation process.Attention should be paid to distinguish the main codes,do not omit"another code"and determine"omitted code".The main coding axis is the surgical approach.The"another code"is slightly different according to the operation situation.This paper uses a copy of lumbar fusion To understand the operation process,determine the materials used in the fusion,cage fusion site,surgical approach,resection site,bone transplantation,number of fusion vertebrae and other conditions during the operation,the complete and accurate classification and coding can be given,which requires the coder not only to carefully read the operation records,master the coding rules,but also to be familiar with the anatomical knowledge,so as to do a good job operation classification and coding.
作者
赵娴
盛春蕊
高阳
穆芳洁
侯春超
Zhao Xian;Sheng Chunrui;Gao Yang;Mu Fangjie;Hou Chunchao(Dongfang Hospital of Beijing University of Chinese Medicine,Beijing 100078,China;不详)
出处
《中国病案》
2020年第5期24-25,共2页
Chinese Medical Record
基金
北京中医药大学2019年度基本科研业务(2019-JYB-JS-126)。
