现代医院2025，Vol.25Issue(8)：1177-1179,1183,4.DOI:10.3969/j.issn.1671-332X.2025.08.009
临床疾病诊断编码库中未特指编码误用问题研究
Misuses of unspecified coding in the clinical disease diagnosis coding library
摘要
Abstract
Objective To explore the causes of misuses of unspecified coding in the clinical disease diagnosis code base mode in a Grade 3A general hospital in order to provide references for the application of clinical disease diagnosis code base and lay a foundation for the comprehensive development of payment by disease points.Methods The study retrieved the first page data of inpatient medical records from January 1,2022,to June 30,2022.It compared the system-generated main diagnostic codes with those reviewed by coders,calculated the error rate of the system's main diagnostic codes,and categorized the reasons for the incorrect use of unspecified coding.Results A total of 3,880 cases misused unspecified coding,accounting for 48.55% of major diagnostic coding errors.The misused unspecified codes were found in 218 subcategories,predominantly in the".9"subcategory.The primary reason for the misuses of unspecified coding was the non-standard documentations of clinicians(81.75%),including errors in writing diagnosis names and incorrect selection of diagnostic core terms.Additionally,the misu-ses were linked to deficiencies in the diagnostic coding library,such as incomplete diagnostic terminology,errors in ICD-10 code mapping,and issues with the national clinical edition coding database expansion.Conclusion In the clinical disease diagnosis coding library model,non-standard documentations by physicians directly impact the accuracy of disease coding.It is essential to improve the quality of disease diagnosis from the source.Coders should engage in deep interaction with clinical departments to en-hance the clinical disease diagnosis coding library,thereby meeting the demands for high-quality disease coding application.关键词
疾病诊断编码库/ICD-10编码/质量控制Key words
Clinical disease diagnosis coding/ICD-10 coding/Quality control分类
医药卫生引用本文复制引用
王晶晶..临床疾病诊断编码库中未特指编码误用问题研究[J].现代医院,2025,25(8):1177-1179,1183,4.基金项目
河北省医学科学研究课题(20240582) （20240582）
