摘要
临床上常用的胰腺癌根治手术在ICD-9-CM-3中主要包括5种分类,分别是根治性胰十二指肠切除术52.7、根治性胰腺次全切除术52.53、根治性胰腺切除术52.7、远端胰腺切除术52.52和其他部分胰腺切除术52.59。对此5种术式编码要点进行整理归纳,列出主要手术编码以及附加手术的另编码和省略编码。通过具体案例阐明胰腺根治手术的编码思路,总结出胰腺癌根治手术常见的编码错误并分析其原因,特别是对名称相近的根治性胰腺次全切除消化道重建术式与根治性胰腺次全切除术进行分析,帮助医师和编码员在临床书写和编码中正确甄别。为提高手术编码质量,医师须完整准确填写手术记录,把好信息源头的质量关;编码员要强化相关临床医学知识的学习,谙熟5种常见术式的分类内涵和解剖切除范围,以及它们通常对应的胰腺恶性肿瘤部位,熟悉消化道重建方法、省略编码和另编码。
In clinical practice,radical surgery for pancreatic cancer is primarily categorized into five types according to ICD-9-CM-3,including:radical pancreatoduodenectomy(52.7),radical subtotal pancreatectomy(Child)(52.53),radical pancreatectomy(52.7),distal pancreatectomy(52.52),and other partial pancreatectomies(52.59).This paper aims to organize and summarize the key points of coding for these five surgical procedures,listing the primary operative codes as well as additional codes and omitted codes for supplementary operations.This paper illustrates the coding logic for radical pancreatic cancer surgery through five specific case studies.It combines the coding quality control practices of a particular hospital to summarize common coding errors in radical pancreatic cancer surgery and analyze their causes.Special emphasis is placed on clarifying the differences between the Child gastrointestinal reconstruction procedure and the Child procedure(52.53),to assist physicians and coders in accurately distinguishing between them during clinical documentation and coding.To improve the quality of operative coding,physicians must carefully and accurately document the operative notes,ensuring the quality of the information at its source.Coders need to enhance their learning of relevant clinical medical knowledge,become proficient in the classification and anatomical resection ranges of the five common procedures,understand the typical locations of pancreatic malignancies associated with these procedures,and be familiar with Methods of gastrointestinal reconstruction,omitted codes,and additional codes.
作者
郭旭升
吴露瑛
张璇
Guo Xusheng;Wu Luying;Zhang Xuan(Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine,Shanghai 200127,China;不详)
出处
《中国病案》
2025年第6期26-29,共4页
Chinese Medical Record
