摘要
髋关节置换及修复术越来越多的出现在关节外科开展的手术中,该类手术是一种具有极高疗效的外科治疗技术,临床分为全髋关节置换术、髋关节部分置换术、髋关节表面置换术、髋关节置换修复术。新的术式产生,新的材料应用,新的伴随手术的出现,对于编码员而言,极大增加了工作量和工作难度,导致了部分错误编码的发生。结合实际手术案例,依据ICD-9-CM-3的原则,讨论分析不同术式正确完整的分类编码及分类规则,总结出该类手术分类编码工作的思路及方法。实际工作中,编码员应掌握该类手术的主要编码和“另编码”的分类规则,然后通过查阅病历中相关内容,分析归纳出该类手术的部位(范围)、术式、假体材料类型、伴随情况等关键点,按照编码查找方法,获取最终编码。最大程度降低分类编码的错误发生。
Hip replacement and prosthesis are increasingly used in joint surgery.This kind of surgery is a surgical treatment technique with high curative effect.It is clinically divided into total hip replacement,partial hip replacement,hip surface replacement and hip replacement repair.The emergence of new operation methods,the application of new materials,and the emergence of new accompanying operations have greatly increased the workload and difficulty of work for coders,leading to the occurrence of some wrong coding.Based on the actual surgical cases and the principle of ICD-9-CM-3,this paper discusses and analyzes the correct and complete classification codes and classification rules of different surgical procedures,and summarizes the ideas and methods of classification coding work of this kind of surgery.In practical work,coders should master the main codes of this kind of surgery and the classification rules of"other codes",and then consult the relevant contents in the medical records.The key points such as the location(scope),operation method,prosthesis material type and accompanying conditions of this kind of surgery were analyzed and summarized,and the final code was obtained according to the code search method.Minimize classification coding errors.
作者
隋亚平
Sui Yaping(Yantai Affiliated Hospital of Binzhou Medical College,Yantai 264100,Shandong Province,China)
出处
《中国病案》
2024年第4期25-28,共4页
Chinese Medical Record
