摘要
临床诊断为宫腔粘连的病例,在ICD-10编码中容易错误地编码为N73. 6,描述为"子宫粘连",实际指的是子宫周围粘连,造成编码错误。而临床更为广泛发生的子宫宫腔粘连的编码为N85. 6,归类于子宫非炎性疾患。另外,仅仅以N85. 6并不能反映病例的全部情况,还应考虑导致宫腔粘连原因和住院目的。如果宫腔粘连是由于与妊娠有关的因素引起的近期并发症,则建议主要编码为O08. 8,归类于流产、异位妊娠和葡萄胎妊娠后的其他并发症;注意如果宫腔粘连是由于与妊娠有关的因素引起的远期并发症,则仍建议主要编码为N85. 6。如果住院目的是由于宫腔粘连导致的不孕,则建议主要编码为N97. 2,归类于子宫起因的不孕症,可用N85. 6作为附加编码说明不孕的原因是宫腔粘连。编码员不仅要熟练掌握ICD-10的分类原则,还应该掌握宫腔粘连的相关医学知识,认真查阅病历,结合具体病情,以提高编码的准确性和质量。
Cases with clinical diagnosis of intrauterine adhesions are easily erroneously coded as N73.6 in the ICD-10 code,described as “uterine adhesions”,which actually refer to adhesions around the uterus,causing coding errors.The more common clinical uterine adhesions are encoded as N85.6,which is classified as a non-inflammatory disease in the uterus.In addition,only N85.6 does not reflect the full extent of the case,the cause of intrauterine adhesions and hospitalization purposes should be taken into consideration.If intrauterine adhesions are due to recent complications associated with pregnancy-related factors,it is recommended that the primary code be O08.8,classified as abortion,ectopic pregnancy,and other complications after hydatidiform mole pregnancy.It should be noted if intrauterine adhesions are Due to long-term complications caused by pregnancy-related factors,the main coding is still recommended as N85.6.If the purpose of hospitalization is due to infertility caused by intrauterine adhesions,it is recommended that the main code be N97.2,which is classified as infertility of the uterus.The coder should not only be proficient in the classification principle of ICD-10,but also master the relevant medical knowledge of intrauterine adhesions,carefully review the medical records,and combine specific conditions so as to improve the accuracy and quality of the coding.
作者
李吉杰
李霞
何伟
李黎
唐雨欣
易玲
LI Jijie;LI Xia;HE Wei;LI Li;TANG Yuxin;YI Ling(Department of Medical Records,the 2 nd Huaxi Hospital of Sichuan University,Chengdu 610041,China)
出处
《现代医院》
2019年第1期42-44,共3页
Modern Hospitals
