摘要
腰椎融合术在治疗腰椎结核、创伤、肿瘤、畸形矫正、退行性疾病等方面得到广泛应用。在ICD-9-CM-3(2011版)中腰椎融合术分类轴心为手术入路和融合部位,主导词查“融合术”,其分类编码于81.06前柱腰和腰骶部融合,前路法;81.07后柱腰和腰骶部融合,后路法;81.08前柱腰和腰骶部融合,后路法。目前腰椎融合方式多样,临床上根据融合部位的不同,通常分为腰椎后外侧融合术、腰椎椎间融合术和腰椎360°融合术。这些术式的手术操作复杂,需要使用多个手术编码体现其手术过程。编码员在实际编码工作中,对融合部位和入路方式的选择、融合椎骨数量、是否应用了融合材料、骨移植等情况理解不清楚会导致手术编码的错编和漏编。本文通过对腰椎融合术编码规则学习、案例解析、分析不同部位融合的编码方法及技术要点,从而提高其手术编码的准确性,为该类疾病诊断相关分组付费的合理实施提供可参考的数据。
Lumbar fusion is widely used in the treatment of lumbar tuberculosis,trauma,tumor,deformity correction,degenerative diseases and so on.In the(ICD-9-CM-3)2011 edition,the classification axis of lumbar fusion is surgical approach and fusion site,and the leading word is"fusion",whose classification code is 81.06 anterior column lumbar and lumbosacral fusion,anterior approach;81.07 posterior column lumbar and lumbosacral fusion,posterior approach;81.08 anterior column lumbar and lumbosacral fusion,posterior approach.At present,there are various ways of lumbar fusion.According to the different fusion sites,it is usually divided into posterolateral lumbar fusion,lumbar interbody fusion and lumbar 360°fusion.The operation of these operations is complex,and multiple operation codes are needed to reflect the operation process.In the actual coding work,the coder's unclear understanding of the selection of fusion site and approach,the number of fusion vertebrae,whether the fusion material is used or not,bone transplantation and other conditions will lead to the wrong coding and missing coding.In this paper,through learning the coding rules of lumbar fusion,case analysis,analysis of coding methods and technical points of different parts of fusion,so as to improve the accuracy of surgical coding,and provide reference data for the reasonable implementation of diagnosis related groups(DRGs)payment.
作者
向思京
Xiang Sijing(Beijing Shijitan Hospital Affiliated to Capital Medical University,Beijing 100038,China)
出处
《中国病案》
2021年第8期53-55,共3页
Chinese Medical Record
