现代医院2024，Vol.24Issue(7)：1048-1050,1054,4.DOI:10.3969/j.issn.1671-332X.2024.07.016
多原发恶性肿瘤ICD-10编码探讨
Discussion on multiple primary malignancy ICD-10 coding
摘要
Abstract
Objective To analyze the coding quality of multiple primary malignant tumors in a tertiary hospital,identify existing problems,and improve the accuracy of coding for multiple primary malignant tumors.Methods We collected 393 medi-cal records from a tertiary hospital from June 1,2021,to June 30,2023,with ICD-10 code C97 for the discharge diagnosis.By carefully reading the medical records,we analyzed the reasons for coding errors in multiple primary malignant tumors with code C97.Results Among the 393 medical records,there were 34 cases with coding errors in C97,including 11 cases where meta-static malignant tumors were erroneously coded as multiple primary malignant tumors,9 cases where malignant tumors of the same organ system with non-adjacent sites and the same histological type were erroneously coded as multiple primary malignant tumors,7 cases where distant metastasis or local invasion was erroneously coded as multiple primary malignant tumors,4 cases where be-nign tumors were mistakenly coded as malignant tumors,and 3 cases where suspected malignant tumors were coded as confirmed cases.Conclusion To improve the quality and efficiency of C97 coding,coders need to have a clear understanding of the defini-tion of multiple primary malignant tumors,read the medical records carefully and completely,determine the location and histolog-ical type of the tumors accurately,and strengthen communication with clinical physicians.关键词
多原发恶性肿瘤/病案质控/ICD-10/疾病编码Key words
Multiple primary malignant tumors/Medical record quality control/ICD-10/Disease coding分类
医药卫生引用本文复制引用
胡颖辉,孔德莹,左煌,闫学丽..多原发恶性肿瘤ICD-10编码探讨[J].现代医院,2024,24(7):1048-1050,1054,4.基金项目
陕西省自然科学基础研究计划(S2023-JC-QN-1422) （S2023-JC-QN-1422）
