目的了解目前吉林省内省医保定点医院的病案首页主要诊断选择与主要诊断ICD-10编码上传质量,找出影响质量的问题所在,提出改进建议。方法从6家省医保定点三甲医院2013年-2014年的出院病案中随机抽取1877份病案,得出各医院6个不同病种上传主要诊断ICD-10编码的现况。结果全部病案中74.37%的病案首页主要诊断选择正确;35.70%的病案上传到省医保部门的主要诊断ICD-10编码是正确的;各个病种在6家医院病案首页主要诊断选择及主要诊断ICD-10编码上传情况是有所差异的,且差异十分悬殊。结论为提高病案首页主要诊断选择与主要诊断ICD-10编码上传的质量,医保部门应和医院通力合作,加强医保部门监管力度,发挥编码人员专业优势,加强人员培训及医院之间的交流,统一并及时更新地区范围内ICD-10编码库,并在此基础上逐步完善其他诊断与手术操作名称编码的上传工作。 Objective To understand the main diagnosis options and the main diagnosis of ICD-10 coded upload quality in the provincial medical insurance designated hospitals in Jilin Province and to find out the problems that affect the quality, and put forward suggestions for improvement. Methods 1877 medical records were randomly selected from the discharged medical records of 6 provincial medical insurance designated hospitals in 2013-2014 to get the current status of the major diagnostic ICD-10 codes uploaded in 6 different medical types of hospitals. Results The main diagnosis of 74.37% of the cases in all the medical records was correct; 35.70% of the cases were uploaded to the provincial medical insurance department for the main diagnosis of ICD-10 coding was correct; and all kinds of diseases were in 6 hospitals. Main Diagnostic Options and Main Diagnostic ICD -10 coding upload situation is different, and the difference is very poor. Conclusion In order to improve the quality of ICD-10 coding and primary diagnosis of primary home page and the quality of ICD-10 coding upload, medical insurance department should work together with the hospital to strengthen the supervision of the medical insurance department, make full use of professional advantages of coders, strengthen staff training and exchange among hospitals, And update the ICD-10 code base in the region in time, and on this basis, improve the upload of other diagnostic and surgical operation name codes.