摘要
直肠前切除术是指经腹保留肛门的下段乙状结肠、直肠癌切除术,是目前应用最多的直肠癌保肛手术。为了提高直肠前切除术编码准确性,结合ICD-9-CM-3(2011版)对直肠前切除术各术式手术编码进行总结,通过案例回顾不同术式的编码。其中结肠肛管吻合术(Parks术)、结肠经肛管拉出术(Bacon术)术中将直肠经肛门拉出属于拖出术,分类于48.4;低位直肠前切除术(Dixon术)、经括约肌间直肠前切除术(ISR术)切除肠管后一期吻合恢复肠管连续性,分类于48.63。根据ICD-9-CM-3(2011版)中另编码、包括等编码原则,直肠前切除术除主要手术编码外还应编码淋巴结清扫(40.59)、肠吻合(46.01/46.21)为附加编码;全直肠系膜切除、肠造口术是直肠前切除术的必要手术步骤,为省略编码。
Anterior rectal resection refers to an abdominal and anus-preserving resection of the lower sigmoid colon and rectal cancer,which is the most widely used anus-preserving surgery for rectal cancer at present.In order to improve the accuracy of coding for anterior resection of the rectum,this study summarizes the surgical coding of each surgical procedure of anterior resection of the rectum combining ICD-9-CM-3(2011 version)and reviews the coding of different surgical procedures through cases.Among them,the pull-out of the rectum through the anus during the Parks and Bacon procedures is classified as pull-out surgery and classified as 48.4;Low anterior rectal resection(Dixon),anterior rectal resection through sphincter(ISR),one-stage anastomosis after intestinal resection to restore intestinal continuity are classified as 48.63.According to the principle of separate coding and equal coding in ICD-9-CM-3(2011),anterior rectal resection should also be coded with additional codes such as lymph node dissection(40.59)and intestinal anastomosis(46.01/46.21)in addition to the main surgical coding.Total mesorectal resection and enterostomy are necessary surgical steps for anterior rectal resection and are not coded.
作者
刘庆
王思思
刘海仙
Liu Qing;Wang Sisi;Liu Haixian(The First Medical center of the General Hospital of the People’s Liberation Army of China,Beijing 100080,China;不详)
出处
《中国病案》
2024年第3期41-44,共4页
Chinese Medical Record
