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目的收集研究ICD-10编码工作中的疑难编码,解决ICD分类无法编码及误码问题,减少误码率,提高ICD-10的分类水平。方法对收集于2004年1月1日至2005年9月1日的326例疑难编码进行原因分析。应用大量的临床专著及文献资料对疑难编码的疾病进行病因、病理、解剖、临床类型的分析研究,然后检索ICD-10分类专著及文献资料,应用灵活的分类技巧,最后确定编码。结果研究解决的编码分三种,“可确定编码”、“基本确定编码”、“拟定编码”。其中“可确定编码”213例,占65.3%；“基本确定”编码76例,占23.3%；“拟定编码”37例,占11.3%。结论全部疑难编码中由于临床诊断与ICD有差异引起的最多,其次是ICD-10未收录的疾病。因此,规范临床诊断,提高编码员的ICD分类技能,根据我国的情况补充ICD编码及索引,对解决疑难编码,提高ICD分类水平有积极的推动作用。
Objective To collect and study the difficult coding in the work of ICD-10 coding, to solve the problems of ICD classification and encoding error, reduce the error rate, and improve the classification level of ICD-10. Methods The causes of the 326 difficult codes collected from January 1, 2004 to September 1, 2005 were analyzed. A large number of clinical monographs and literature data were used to analyze the etiology, pathology, anatomy, and clinical types of difficult-to-code diseases. Then ICD-10 monographs and literature were searched, flexible classification techniques were applied, and coding was finally determined. Results There are three types of codes to be solved in the study: “determinable coding”, “basic coding determination”, and “preparation coding”. Among them, 213 cases can be identified, accounting for 65.3%; 76 cases are basically coded, accounting for 23.3%; 37 cases are intended to be coded, accounting for 11.3%. Conclusions Most of the difficult-to-follow codes were caused by differences in clinical diagnosis and ICD, followed by diseases not included in ICD-10. Therefore, standardize the clinical diagnosis, improve the ICD classification skills of the coders, supplement the ICD codes and indexes according to the situation in China, and play a positive role in solving difficult codes and improving the ICD classification level.