摘要
输卵管和卵巢二者合称为子宫附件,附件手术是妇科的常见手术,包括单侧附件切除术、双侧附件切除术、单侧输卵管切除术、单侧卵巢切除术和卵巢输卵管部分切除术等术式。通过剖析输卵管及卵巢的手术案例,总结临床医师书写的手术名称与ICD-9-CM-3手术分类名称存在差异。输卵管及卵巢作为成对的性腺器官,同样的手术范围、术式名称,手术编码会因为疾病性质、手术结局、目的不同而出现差异。“残留/孤立”的输卵管及卵巢切除应编码在相应双侧全部切除的亚目中,如“单侧输卵管切除术,仅切除一侧,保留对侧”,编码于66.4单侧输卵管全部切除术,而66.52残留/孤立输卵管切除及66.51一次性切除双侧输卵管均归类于亚目66.5双侧输卵管全部切除术。当疾病性质系输卵管妊娠行“单侧输卵管切除术”,编码于66.62输卵管切除术伴去除输卵管妊娠。
The fallopian tube and ovary are called the adnexa uteri.Adnexa operation is a common operation in gynecology,including unilateral adnexectomy,bilateral adnexectomy,unilateral salpingectomy,unilateral oophorectomy and partial salpingo-oophorectomy.By analyzing the operation cases of fallopian tube and ovary,the differences between the operation name written by the clinician and the classification name of ICD-9-CM-3 operation were summarized.Fallopian tube and ovary as pairs of gonadal organs,the same scope of operation,the name of the operation,the operation code will be different because of the nature of the disease,the outcome of the operation,the purpose of the different."Residual/isolated"removal of fallopian tubes and ovaries should be coded in the corresponding bilateral total removal suborder,such as"unilateral salpingectomy,removal of only one side,leaving the opposite side",coded in 66.4 unilateral total salpingectomy.66.52 residual/isolated salpingectomy and 66.51 unilateral salpingectomy were classified in subhead 66.5 bilateral total salpingectomy.When the nature of the disease is tubal pregnancy"unilateral salpingectomy"is performed,coded in 66.62 salpingectomy with removal of tubal pregnancy.
作者
柯雅君
翁禾
Ke Yajun;Weng He(Department of Medical Records,The First Affiliated Hospital,Fujian Medical University,Fuzhou 350005,Fujian Province,China;不详)
出处
《中国病案》
2024年第6期49-51,共3页
Chinese Medical Record
