摘要
随着病案首页ICD编码在医保付费、医院管理和临床科研等的作用日益重要,医疗行业对ICD编码准确性提出更高要求。ICD编码准确性不仅指主要诊断和主要手术编码准确,也包括其他诊断编码准确。但在实际工作中对其他诊断ICD编码准确性重视较少,不规范填写情况较多。术后状态则是其他诊断中最常见也较为特殊的诊断描述。本文主要探讨了术后状态的编码分类和编码应用,侧重强调了Z89-Z90、Z93-Z96和Z98.8及Z92.4的区别,再用实际案例阐述了术后状态编码在病案首页的正确用法,以期为ICD编码提供参考。
With the increasing importance of ICD coding on the front page of medical records in medical insurance payment,hospital management and clinical research,the medical industry has put forward higher requirements for the accuracy of ICD coding.The accuracy of ICD coding not only refers to the accuracy of major diagnosis and major surgical coding,but also includes the accuracy of other diagnostic coding.However,in practical work,less attention is paid to the accuracy of ICD coding for other diagnoses,and there are more non-standard fillings.Postoperative status is the most common and special diagnostic description in other diagnoses.This paper mainly discusses the coding classification and coding application of postoperative status,focusing on the differences between Z89-Z90,Z93-Z96,Z98.8 and Z92.4,and then expounds the correct usage of postoperative status coding on the front page of medical records with practical cases,in order to provide reference for ICD coding.
作者
展定莹
ZHAN Ding-ying(Medical Records Management Office,Sichuan Second Hospital of Traditional Chinese Medicine,Chengdu 610000,Sichuan,China)
出处
《医学信息》
2024年第6期47-51,共5页
Journal of Medical Information
