摘要
脾组织植入是因后天因素所致的一种疾病,特点是在各种解剖部位出现脾组织的自体植入,常被误诊或怀疑为恶性肿瘤,入院行手术后确诊。通过1例脾组织在肝脏和腹腔多发植入病例,分析主要诊断选择及其相应的ICD-10编码查找过程。当针对脾组织植入结节手术时,不论其植入部位或手术部位,均应以脾组织植入为主要诊断;其ICD-10编码查找的关键是选择脾组织植入为主导词,编码为D73.8,现行国家临床版2.0尚无具体对应编码,可选择D73.800脾的其他疾病,保证编码内涵准确,待编码库升级后再作统一调整。脾组织植入结节需与先天性副脾鉴别。因其中文翻译多种,使用工具书查找ICD-10编码时确定主导词较困难。仔细阅读病案和积极查阅文献,有助于主要诊断和ICD编码的准确选择。
Splenosis is a disease caused by acquired factors(such as trauma or splenectomy),which is characterized by autoimplantation of viable splenic tissue throughout various anatomic compartments.It is often misdiagnosed or suspected as a malignant tumor,and diagnosed by surgery.Based on a case of splenosis,the selection of main diagnosis and the search process of the corresponding ICD-10 code was analyzed.When splenic autoimplant nodule resection is performed,splenosis should be selected as the main diagnosis,regardless of its implantation site or operation site;The key to ICD-10 code search is to select"splenosis"as the keyword,and the code is D73.8.Since there is no corresponding code in the current ICD-10 code database of national clinical version 2.0,“D73.800 other diseases of spleen”can be selected first.Unified adjustments will be made after the ICD-10 code database is upgraded.Splenic autoimplant nodules should be differentiated from congenital accessory spleen.
作者
张弘
王凯鹏
钟雪梅
庞倩云
荣维淇
尹世全
Zhang Hong;Wang Kaipeng;Zhong Xuemei;Pang Qianyun;Rong Weiqi;Yin Shiquan(Department of Medical Record,National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100021,China;不详)
出处
《中国病案》
2023年第5期40-42,共3页
Chinese Medical Record
基金
医院管理研究课题专项基金资助(LC2019D01)。
