摘要
骨质疏松症是一种常见的全身性骨病,临床书写诊断经常遗漏病因导致编码错误。结合临床分类和ICD-10编码分类规则,原发性骨质疏松中绝经后、老年性、特发性骨质疏松伴有脆性骨折归类于M80.0、M80.8、M80.5,不伴有脆性骨折归类于M81.0、M81.8、M81.5;继发性骨质疏松中卵巢切除术后、失用性、手术后吸收不良性、药物性骨质疏松伴有脆性骨折归类于M80.1-M80.4,不伴有脆性骨折归类于M81.1-M81.4,见于某些其他疾病引起的骨质疏松采用星剑号编码M82*;局限性骨质疏松M81.6在ICD-11中已废除。在实际工作中编码员要加强临床知识学习,通过与临床沟通鉴别骨质疏松的病因,注意药物性骨质疏松的另编码和脆性骨折的细目编码,确保骨质疏松症相关疾病编码的完整性和准确性。
Osteoporosis is a common systemic bone disease, and clinical written diagnoses often omit the cause,leading to coding errors. Combining clinical classification and ICD-10 coding classification rules, postmenopausal,senile, and idiopathic osteoporosis with fragility fractures are classified as M80.0, M80.8, and M80.5, while those without fragility fractures are classified as M81.0, M81.8, and M81.5. Osteoporosis caused by post-oophorectomy,disuse, post-operative malabsorption, and drug-induced osteoporosis with fragility fractures is classified as M80.1-M80.4, and osteoporosis without fragility fractures is classified as M81.1-M81.4. Osteoporosis caused by certain other diseases is coded as M82*. Localized osteoporosis M81.6 has been abolished in ICD-11. In actual work,coders should strengthen their clinical knowledge learning, identify the causes of osteoporosis through clinical communication, pay attention to the additional coding of drug-induced osteoporosis and the detailed coding of fragility fractures, and ensure the completeness and accuracy of osteoporosis-related disease coding.
作者
楚伟明
王佳杰
管蔚
刘俊杰
Chu Weiming;Wang Jiajie;Guan wei;Liu Junjie(The Central Hospital of Yangpu District,Shanghai 200090,China)
出处
《中国病案》
2025年第1期41-43,共3页
Chinese Medical Record
