摘要
分析新生儿疾病ICD-10疾病分类编码和ADRG分组特点,列举和讨论新生儿疾病6个常见的ICD-10编码和ADRG入组错误案例:包括新生儿腹泻未区分感染性与非感染性、新生儿肺炎未分类到先天性肺炎、早产儿与低出生体重儿的主要诊断选择错误、新生儿的呼吸机治疗操作漏编码、气管内插管未与呼吸机治疗联合使用、错误使用新生儿黄疸P59.900统计代码当疾病分类编码,因此造成了新生儿病例的核心疾病诊断相关分组入组错误,并给出质控后正确的疾病、手术操作编码和正确的核心疾病诊断相关分组。阐明影响新生儿科病例核心疾病诊断相关分组入组的主要因素包括特定疾病编码错误、主要诊断选择错误、漏填重要的手术操作、主要手术操作选择错误等需引起临床医师和编码员的高度重视。建议不论是临床医师还是编码员,都应熟知疾病分类编码和DRG分组规则,正确的疾病编码、正确的选择主要诊断和规范填写手术操作名称是ADRG正确入组的关键所在。
This paper analyzes the characteristics of ICD-10 disease classification coding and ADRG grouping of neonatal diseases, enumerates and discusses 6 common ICD-10 coding and ADRG group errors of neonatal diseases: neonatal diarrhea does not distinguish between infectious and non infectious, neonatal pneumonia is not classified into congenital pneumonia, major diagnostic selection errors of premature and low birth weight infants, and missing codes of neonatal ventilator treatment In addition, endotracheal intubation was not used in combination with ventilator treatment, and neonatal jaundice(P59.900) statistical code was used as disease classification code, which resulted in the error of ADRG in neonatal pediatric cases. The correct disease, operation code and correct ADRG grouping after quality control were given. To clarify the main factors that affect the admission of ADRG in neonatology cases, including coding errors of specific diseases, errors of main diagnosis selection, omission of important surgical operations, and wrong selection of major surgical operations, which should be paid great attention by clinicians and coders.
作者
明平勇
柯珊红
Ming Pingyong;Ke Shanhong(Edong HealthCare HuangShi Central Hospital,Huangshi 435000,Hubei Province,China)
出处
《中国病案》
2021年第4期41-43,共3页
Chinese Medical Record
