摘要
纵隔原发性肿瘤是胸外科常见疾病,通过案例分析梳理纵隔原发性肿瘤的疾病及手术操作编码。建议ICD-10将A型、AB型、B1型、B2型、B3型、化生型、NOS(未特指分型)胸腺瘤分类在C37.X胸腺恶性肿瘤,ICD-11分类于2C27.2恶性胸腺瘤;微结节性胸腺瘤伴淋巴样间质胸腺瘤ICD-10分类到D38.4胸腺动态未定或动态未知的肿瘤,ICD-11分类到2F71.0胸腺生物学行为不定的肿瘤;胸腺脂肪纤维腺瘤ICD-10分类于D15.0胸腺良性肿瘤,ICD-11编码为2F01胸腺良性肿瘤。纵隔神经鞘瘤ICD-10归类到D36.1周围神经和自主神经系统良性肿瘤,ICD-11分类在2F3Y其他特指部位的良性非间叶性肿瘤。纵隔成熟型畸胎瘤ICD-10分类于D15.2纵隔良性肿瘤,ICD-11编码为2F01纵隔良性肿瘤;纵隔未成熟型畸胎瘤ICD-10分类于C38.1前纵隔恶性肿瘤、C38.2后纵隔恶性肿瘤和C38.3部位未特指的纵隔恶性肿瘤,ICD-11编码为2C28.0心脏、纵隔或胸膜非间皮瘤的恶性生殖细胞肿瘤。常见手术编码有07.81胸腺部分切除术、07.82胸腺其他全部切除术、07.83胸腔镜下胸腺部分切除术、07.84胸腔镜下胸腺全部切除术、04.07颅和周围神经的其他切除术和撕脱术、34.3纵隔病损或组织的切除和破坏术。编码的要点在于区分肿瘤起源、性质及手术方式,编码员不仅需要掌握疾病及手术的分类规则和不断学习纵隔肿瘤的WHO的新分型,在实际的编码过程中,还需要做到通读病案,理解疾病性质和相应的手术部位及术式,这样才能进一步提高纵隔原发性肿瘤的编码水平。
Mediastinal primary tumor is a common disease in thoracic surgery.The disease and operative code of mediastinal primary tumor were analyzed by case study.It is suggested that ICD-10 classify thymomas of type A,AB,B1,B2,B3,chemogenetic type,NOS(not specifically referred to as type)as C37.X thymoma and ICD-11 as 2C27.2 malignant thymoma.Micronodular thymoma with lymphoid stromal thymoma was classified by ICD-10 as D38.4 tumors with uncertain or unknown thymus dynamics,and by ICD-11 as 2F71.0 tumors with uncertain thymus biological behavior.The ICD-10 classification of lipofibroadenoma of the thymus is D15.0 benign tumor of the thymus,and the ICD-11 code is 2F01 benign tumor of the thymus.Mediastinal schwannomas were classified as benign peripheral and autonomic nervous system tumors by ICD-10 and benign non-mesenchymal tumors by ICD-11 in 2F3Y and other specific sites.Mature mediastinal teratoma was classified as D15.2 mediastinal benign tumor by ICD-10,and 2F01 mediastinal benign tumor by ICD-11.The ICD-10 classification of mediastinal immature teratoma is premediastinal malignancies of C38.1,postmediastinal malignancies of C38.2,and mediastinal malignancies not specifically specified at C38.3.The ICD-11 code is 2C28.0 malignant germ cell tumors of the heart,mediastinum,or pleura that are not mesothelioma.Common procedures included 07.81 partial thymotomy,07.82 total thymotomy,07.83 thoracoscopic partial thymotomy,07.84 total thoracoscopic thymotomy,04.07 other excision and avulsion of cranial and peripheral nerves,and 34.3 excision and destruction of mediastinal lesion or tissue.The key point of coding is to distinguish the origin,nature and surgical methods of tumors.Coders not only need to master the classification rules of diseases and surgeries and constantly learn the new types of mediastinal tumors by WHO,but also need to read through medical records to understand the nature of diseases and corresponding surgical sites and methods in the actual coding process,so as to further improve the coding level of pri
作者
陈淡芬
林静
边壮
张宝珍
许萍
Chen Danfen;Lin Jing;BianZhuang;Zhang Baozhen;Xu Ping(Zhuhai Medical Record Quality Control Center,The Fifth Affiliated Hospital of Sun Yat-sen University,Zhuhai 519000,Guangdong Province,China)
出处
《中国病案》
2024年第4期31-34,共4页
Chinese Medical Record
